AAddvvaanncceess iinn MMeeddiiccaall && SSuurrggiiccaall AAnntteerriioorr SSeeggmmeenntt TThheerraappyy J. James Thimons, O.D.,FAAO Optometric Medical Director Ophthalmic Consultants of Connecticut
CCrroossss LLiinnkkiinngg:: NNeeww TTeecchhnnoollooggyy ffoorr aanndd OOlldd DDiisseeaassee KCN Diagnosis Corneal Collagen Cross-Linking Creates chemical bonds between fibers
Floppy Eyelid Syndrome Cross-Linking is Not New Hardening of polymers in materials science since 1930s (silicone oil→rubber ball) Dentists X-linked for decades Normal aging of connective tissue involves cross-linking and stiffening Progression of KCN↓ with age as XL↑ We All “Crosslink” as we Grow Up Transplant Risks Before and After Crosslinking CCXXLL iinn KKeerraattooccoonnuuss Shown safe and effective worldwide Arrest progress of KCN Improvement in UCV, BCSVA, CLs Ideal candidates ≤ 45 y/o, corneal thickness ≥ 400 µm, limited scarring Minimum age in Europe now 10 y/o CXL and Ectasia Kannalopoulos, J Review of CXL post LASIK with ectasia Analysis at one year – Corneas stable – Mild refractive error shift No PK required at two years CXL and PRK Requires wavefront scan at level 4 reliability Predictability is less than standard PRK Contraindicated with apical scar Post-op similar to standard PRK CL’s same algorithm
Radial Keratotomy CXL Technique
UV-A Light 370 CXL Post-operative Care – 1 day, 1 week, & 1 month recommended visits – 4th generation fluoroquinolone qid x 4 days – Durezol or PF taper x 3 weeks – BCL – NPATS Haze?
CXL Post Epi-On CXL Contact Lens Tx – Soft lens several days – HCL 1 week – Hybrid 2 weeks Topo’s at 3M/ 6M Crosslinking can continue up to 6M Indications for Intacs Step 1: Intralase Intacs Channel Creation
Post-Operative Management Issues Managing MGD in the Primary Care Setting OM3’s Cycline’s Hot compresses Lid Hygiene Meibomian Gland Expression Lipiflow Because Not All MGD Is Obvious, Active Disease Identifiication Is Crucial Meibomian Glands
Meibomian Gland Expression Arita Meibomian Gland Expression System With or without anesthesia Grade I-IV Non- billable More difficult at the punctal region.
LLiippiiFFllooww // LLiippiiVViieeww AA NNeeww PPaarraaddiiggmm iinn MMeeiibboommiiaann GGllaanndd DDiisseeaassee TTrreeaattmmeenntt Meibomian Gland Expression and Gland Functionality MGD and Lipid Layer Thickness TTeeaarrSScciieennccee®® SSoolluuttiioonn
LipiView® Output
Because Not All MGD Is Obvious, Active Disease Identification Is Crucial Normal Meibomiian Glands Posterior Lid Margin Disease Clinical Findings – Posterior Lid margin – Inspissation of glands Erythema & telangiectasia – Pouting of oil – Gland drop out – Rapid tear break up time Bacterial Lipases Breakdown Lipids to Soap Meibomian Glands LipiFlow® Thermal Pulsation System
LipiFlow® Thermal Pulsation System LipiView/ LipiFlow LipiView – Reimbursement: $ 125.00 Lipiflow – Reimbursement: $1000.00-1,500.00 Point of Care Diagnostic Systems: The Next Step in Anterior Segment Care RPS Adenodetector Tear Lab Inflamma-Dry LacriPen Laboratory Testing Primary Care: A Paradigm Shift Laboratory Testing Acute Conjunctivitis Adenoviral Conjunctivitis Clinical Accuracy
AdenoPlus
How to Use AdenoPlus: Four-step Process RPS Adeno Detector Plus InflammaDry InflammaDry: Defining the Role of MMP-9 in Dry Eye? MMP-9 and Dry Eye Severity1 Limit of Detection How to Use InflammaDry: Four-step Process Future Advances in Tear Marker Assessment Tear markers that currently exist: – Osmolarity – Adenovirus – MMP-9
IgE, HSV Alzheimer's Diabetes Parkinsons?
Tear Function Screening Questionnaire Gritty or sandy sensation? Pain or soreness? Fluctuating vision? Occasional Tearing? Blurred vision while reading? Discomfort in windy conditions? Discomfort in air conditioned areas? Itching?
Possible Testing During Dry Eye Evaluation Tear Break Up Time CCoonnjjuunnccttiivvaall SSttaaiinniinngg
SScchhiirrmmeerr SSttrriippss
Summary Statistics on Tear Osmolarity Normal subject average: – 296 ± 8 mOsm/L Dry Eye subject average: – 323 ± 16 mOsm/L
Normal subject inter-eye difference: – 7 ± 6 mOsm/L Dry Eye subject inter-eye difference: – 17 ± 15 mOsm/L – Inter-eye difference is the hallmark of DED ( > 8 mOsm/L between eyes)1 Osmollariity iin the Diiagnosiis of Dry Eye Diisease Osmolarity is the “gold standard” test for Dry Eye – 45 years peer reviewed research – Osmolarity has been added to definition of Dry Eye – Global marker of Dry Eye, indicating a concentrated tear film
Tear Osmolarity (Tomlliinson 2006) KEEP IT SIMPLE AND TAKE ADVANTAGE OF PPV Osmolarity & Tear Film Instability in DED Two Numbers Crucial to Understand Osmolarity The DIFFERENCE b/w two eyes: 24 This tells you how stable the tear film is. Normal tears are stable and < 300 mOsm/L bilaterally. A difference of > 8 mOsm/L is a hallmark of tear instability. Tear Lab Reimbursement – NGS:$ 44.50 – Medicaid: $ 43.50 – Commercials: $ 29-40 Code: 92071 Card cost: $10 Symptoms of Dry Eye Signs of Dry Eye PPootteennttiiaall CChhrroonniicc CChhaannggeess Telangiectasia
Dislocation of meibomian glands/ gland atrophy
Scarring Treatment Recommendations by Severity Levels
Treatment Recommendations by Severity Levels
EXTEND™ Synthetic Absorbable Implant
Billing for Punctal Occlusion 68761 Punctal Occlusion Permanent or Temporary – E Codes E1 Superior Left E2 Inferior Left E3 Superior Right E4 Inferior Right – NGS reimbursement: $168.64 – Silicon Plug cost: $40-50 – Extended Collagen: $7-8
Developing Treatment Protocols Nutritional Supplements – Omega 3 fatty acid Fish Oil (EPA and DHA) Flaxseed – GLA – Vitamins The Hypothesis behind “The Root Cause” of Dry Eye Omega Imbalance (excess Omega-6:Omega-3) – causes the meibum to become thick, viscous and inflamed – causes the Meibomian Glands to become blocked – prevents the production of the lipid layer
Without the lipid layer, the aqueous layer evaporates, causing the ocular surface to become irritated (red, dry, scratchy) Dosing Protocol – Dry Eye Omega Benefit Therapeutic Dose -Four capsules daily with meals Treatment Recommendations by Severity Levels Treatment Recommendations by Severity Levels Moderate to Severe Treatment Recommendations by Severity Levels Persistent Epithelial Defects Treatment cyanoacrylate tarsorrhaphy – Indications lagophthalmos exposure keratitis neurotrophic keratitis dry eyes persistent epithelial defects Persistent Epithelial Defects Treatment cyanoacrylate tarsorrhaphy – Indications lagophthalmos exposure keratitis neurotrophic keratitis dry eyes persistent epithelial defects Temporary Cyanoacrylate Tarsorrhaphies Age (27-85) 62 Dx: – Persistent epithelial defects – Neurotrophic keratitis – Exposure keratitis – Lagophthalmos
Product Specifications PROKERA® PLUS PROKERA® SLIM Amniotic Membrane ProKera ( Biotissue) IOP Ocular Surface Disease Pathology Inflammation’s Effect on Healing . Inflammation: the first sign of wound healing & is also the hallmark symptom of all ocular surface diseases . Uncontrolled inflammation leads to: . Chronic pain and discomfort/irritation . Delayed healing, more tissue damage . Vision-threatening complication, e.g., scar/haze . Effective control of inflammation is an important strategy to promote healing and minimize the risk of scar/haze
Different Outcomes to Tissue Injury Scarring is more than just the risk of vision loss… Ophthalmologists Are Aware of the Importance & Challenges of treating Ocular Surface Inflammation Emerging Treatment Paradigm Emerging Therapeutic Options Amniotic Membrane Power of the Amnion KEY Amniotic Membrane Components
Recommended Pre-Treatment Tips
Published Case Review Published Case Review Case Study 3: Acute Chemical Burn Recommended Post Treatment Tips ProKera Reimbursement – $1,628.38 Code: 65778 OOccuullooppllaassttiicc PPrroocceedduurreess ffoorr tthhee PPrriimmaarryy CCaarree CClliinniicciiaann J. James Thimons, O.D., FAAO Comprehensive Lacrimology Therapy Includes Therapeutics – Topical – Oral Includes Punctal Occlusion Dilation & Irrigation Nasolacrimal Probed Multiple Medical Visits
PPrreeddiissppoossiinngg ffaaccttoorrss Age Gender Environment Anterior Segment Disease Medications CL Wear Refractive surgery Systemic Disease Pathophysiology of Epiphora Increased Reflex Tear Production – Rapid tear break up time – OSDI – Ocular surface irritation – Corneal changes: Punctate epithelial erosions Infiltrates related to staph hypersensitivity Decreased Outflow – Punctal Stenosis – Naso-Lacrimal obstruction – Anatomic Abnormality Floppy Lid Ectropian/Entropian Trichiasis – Dacryocystitis
Managing Dacryocystitis Antibiotic Therapy Important Penicillins Ampicillin: Broad spectrum oral-QID dosing Amoxicillin: Pro-drug of Ampicillin, improved absorption with lower GI side-effects Cloxacillin/Dicloxacillin: Intrinsic beta-lactamase resistance Augmentin: Amox + Clavulanate Methicillin: IV prep for penicillinase producers Amp + Sulbactam: Unasyn: IV Ticarcillin + Clavulonic acid: IV better penicillinase protection than methacillin Augmentiin Indiicatiions/Dosage forms Indications: Preseptal cellulitis Dacryocystitis Pediatric Hemophilus Amoxicillin + Clavulanate@@@@ Dosage forms: 500 or 875mg tablets BID 125 or 250mg/5cc pediatric suspension
Plan B: The Cephalosporins Mechanism: Same as penicillin Bacteriostatic Low toxicity 3% allergic to pen are allergic to Ceph. Better penicillinase resistance than penicillins Second Generation: Greater Gram (-) activity, especially Hemophilus Cefaclor: PO-Ceclor Cefuroxime: PO-Ceftin
Third Generation: Reduced GR (+) activity (Staph sp) with marked Gr (-) activity Cefixime: PO- (Suprax) Cefpodoxime: PO - Vantin Cefprozil: PO - Cefzil
Anatomy
Illustrative Problematic Case 60 yo white female with long standing history of blepharitis associated with acne rosacea Has been on various blepharitis regimens and seen numerous eye care providers Continues to have daily, intermittent pooling of tears and carries tissue to wipe her eyes Exam shows improved appearance of her lid margins Cicatricial Ectropion Chronic irritation from blepharitis and tearing can lead to cicatricial changes of eyelid skin Chronic wiping can exacerbate age-related laxity of lid Exposure and hypertrophy of conjunctiva increases tendency of lid to evert Floppy Lid Sydrome C:\Documents and Settings\James Thimons\Desktop\photo.JPG Punctal Stenosis
Dilation & Irrigation Equipment – Sterile saline – Pediatric/Adult dilator – 1 or 3 ml syringe – 135 degree canulla Clinical pearl: Use antibiotic or steroid in syringe to enhance taste by patient
Naso-lacrimal Probe Equipment – Pediatric / Adult dilator – Bowman’s probe( multiple diameters) – Sterile saline – Anesthetic – Syringe – Cannula
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Mini Monoka FCI ophthalmics
Punctal/Canalicular Intubation for Punctal Stenosis Advantages – Quick, in office procedure under topical anesthesia – In experienced hands, essentially no risk – Easy to remove Disadvantages – Epiphora may increase over short term due to footplate occlusion of punctum – Problem may recur if underlying inflammation inadequately treated – No good billing code for procedure
Naso-Lacrimal Procedures Re-imbursement – D&I: $143.15 – NLP: $278.61 Codes D&I 68801 NLP 68810
Anterior Segment Surgical Procedures Debridement Anterior Basement Membrane Micropuncture Complex Foreign Body Management Cyanoacrylate Procedures
Recurrent Erosions Pathophysiology - basal epithelial basement membrane misdirection results in: – Thickened basement membrane – Reduplicated basement membrane – Intraepithelial pseudocysts – Lack of hemidesmosomes Recurrent Erosions Clinical Etiology – Primary Epithelial dystrophies (MDF, Meessman’s) Bowman’s membrane dystrophy (Reis-Bucklers) Stromal dystrophies (macular, lattice, granular)
Rodriiguez MM, Fiine BS, Laiibson PR, Ziimmerman LE. Diisorders of the corneall epiithelliium. A clliiniicopathollogiic study of dot, geographiic, and fiingerpriint patterns. Arch Ophthallmollogy 1974;92:475-82 Recurrent Erosions Contributing Factors –Dry eyes –Blepharitis –External disease / tear film abnormalities
The Cyclines Tetracycline, Doxycycline and Minocycline – Isolated from Streptomyces – Effective against Gram +/ Gram -/Aerobic/ Anerobic/ Spirochetes/Rickettsia/Chlamydia – Similar action / different duration
The Cyclines Clinical Applications – Brucellosis – Rickettsia ( Rocky Mountain Spotted fever) – Lyme Disease – Chlamydia/ Trachoma – Primary Meibomianitis – Gonococcal Prophylaxis – “Corneal melting” Syndrome – Non Healing Corneal lesions – Rosacea
Recurrent Erosions Surgical Management –Epithelial debridement chalazion curette 57 Beaver Blade
Case A
46 y/o male physician 5 years s/p LASIK complains of decreased vision OD over past 4 years presents for refractive consultation for CXL. – Manifest
OD +1.25-4.25 X 95 20/70 – Pachymetry
OD 460 microns
file:///C:/Documents%20and%20Settings/James%20T himons/Desktop/Debridement%20video.htm Recurrent Erosions Anterior Basement Membrane Puncture –20-gauge needle
FOREIGN BODIES CORNEAL/ CONJUNCTIVAL – HISTORY – TESTING VA ( WITH AND WITHOUT PINHOLE) PUPILLARY STATUS – ANISOCORIA – IRREGULAR SHAPE(OVAL)
Foreign Bodies Superficial 65220, 65222, 65205, 67938
Penetrating add 76529
Perforating 76529, (65235)
FOREIGN BODIES PENETRATING – LODGED IN TISSUE CAREFUL INSPECTION/ REMOVAL REFERRAL CT SCAN PERFORATING – HISTORY IS CRITICAL – TRIAGE/REFER
Lids and Adnexa Lacerations 870.0 99203, (67930) – Hydrogen peroxide – Simple closure, topical and system antibiotic – Tetanus toxoid
Ecchymosis 921.0
Ptosis 374.3 92081, 92285
NB: Supplemental procedures must be documented on separate forms.
Anterior Segment Procedures Codes: – Corneal Debridement: 65435 / $91.25 – Penetrating FB: 65222/ $79.07 – Corneal FB: 65222/
Keys to Success in Complex Viral Disease Betadine Prophylaxis Pseudomembrane Debridement Stromal HSK Iridocyclitic HSK Recuurent HZK Epidemic Keratoconjunctivitis EKC – Serotypes 8,19 most typical – Seasonal – Primarily bilateral – Atypical serotypes; Enterovirus 70 Clinical Presentation – Chemosis – Injection – Infiltrates – Ac/reaction? – FBS
EKC Treatments – Palliative Cold compress Tears – Interventional Anti-inflammatory agents Decongestants Combination agents Cidofovir Betadine Zirgan?
EKC Treatments – Betadine wash – Surgical Debridement
EKC Betadine Protocol Topical anesthetic x 2 Non Alcohol betadine applied to inferior/ superior cul de sac One minute wait Rinse with artificial tears Apply Topical steroids x 3-4 in post treatment period
EKC Betadine Protocol Clinical “Pearls” – Most effective if treated within 3 days of onset – Less effective in advanced cases – SPK incidence is close to 100% – Patients will complain of FBS 1-2 hours later
ZIRGAN® (ganciclovir ophthalmic gel) 0.15% The Antiviral for the 21st Century Zirgan 0.15% Gel Sirion Pharmaceuticals HSK 2 years and older Ganciclovir: Selectively targets replication of HSV DNA within corneal cells Dose: 5 x / day till lesion resolves then tid for one week Toxicity: – 60% blur – 20% irritation – 5% Hyperemia
ZIRGAN® Mechanism of Action Adenovirus Adenovirus clinical trial (Tabbara, 2001) Herpes Simplex Keratitis Incidence and Prevalence
ANTI-VIRALS CLINICAL APPLICATIONS – ACUTE VS CHRONIC INFECTION – PRIMARY LESIONS – EPITHELIAL HERPES SIMPLEX – STROMAL HERPES SIMPLEX – HERPES ZOSTAR – HERPETIC IRIDOCYCLITIS Oral Antivirals
Oral Antivirals ANTI-VIRALS SIDE EFFECTS – RENAL FAILURE/ IMPAIRMENT – HYPERSENSITIVITY REACTIONS – FACIAL EDEMA – VISUAL HALLUCINATIONS
FFaammvviirr ((ffaammcciicclloovviirr)) Pharmacology: –Synthetic nucleoside (guanine) analog, prodrug of penciclovir. Penciclovir conversion into acyclovir triphosphate inhibits herpes virus-specific polymerases & produces viral DNA termination. Formulation: –125, 250 and 500 mg tablets. Usual Dosage: –Adults: 500 mg q8h x 7 days (HZV) –Children: Safety not fully evaluated. Indications: –HZV ophthalmicus, suppression of recurrent HSV keratitis. Safety/efficacy of long-term HSV suppressive tx not fully established. ZZoovviirraaxx ((aaccyycclloovviirr)) Pharmacology: –Synthetic purine (guanosine) nucleoside analog. Acyclovir is phosphorylated by the enzyme thymidine kinase which is encoded by herpes viruses (HSV-1, HSV-2, HZV). Acylovir triphosphate selectively inhibits herpes-specific polymerase which, in turn, produces viral DNA termination. Formulation: –400 and 800 mg tablets. Usual Dosage: –Adults: 800 mg 5x qd x 7 days (acute HZV). –Children: Safety and efficacy not fully evaluted in ocular disease mgmt. Indications: –HZV ophthalmicus, suppression of recurrent HSV keratitis. 400 mg bid for up to 1 yr. for chronic suppressive tx. (greatest benefit in recurrent, vision threatening stromal HSV keratitis or cases where vision loss from HSV epith. keratitis is a concern). VVaallttrreexx ((vvaallaaccyycclloovviirr HHCCll)) Pharmacology: –Synthetic purine (guanosine) nucleoside analog, prodrug of acyclovir. Valacyclovir is almost completely converted to acyclovir by first pass intestinal and/or hepatic metabolism. Formulation: –500 and 1000 mg tablets. Usual Dosage: –Adults: 1000 mg q8h x 7 days (HZV). –Children: Safety not fully evaluated. Indications: –HZV ophthalmicus, suppression of recurrent HSV keratitis. Safety/efficacy of long-term HSV suppressive tx not fully established, but likely comparable to acyclovir.
HSK STROMAL KERATITIS – RULE OUT MICROBIAL DISEASE – VIROPTIC – ORAL AGENTS – CORTICOSTEROIDS – CYCLOSPORINE A – SURGERY PKP CONJUNCTIVAL FLAPS TISSUE ADHESIVES
VARICELLA ZOSTAR- KERATITIS PRIMARY INFECTION – CHICKEN POX – VACCINATION RECOMMENDED BY AMERICAN ACAD of PEDIATRICS RECURRENT INFECTION – OPHTHALMIC INVOLVEMENT 10-255 – OPHTHLAMIC ZOSTAR > OVER AGE 60 – UNDER 40 50% IIMMUNOCOMPRIMISED
TTrraauummaa MMaannaaggeemmeenntt Blow-Out Fracture Blow-out Fracture Symptoms – Pain (especially on attempted vertical eye movement), local tenderness, double vision, eyelid swelling, crepitus after nose blowing Signs – Restricted eye movement, subcutaneous or conjunctival emphysema, hypesthesia in distribution of infraorbital nerve
Blow-out Fracture Treatment – Nasal decongestants – Broad-spectrum oral antibiotics for 7 days may be used but are not mandatory – Instruct patient not to blow nose – Apply ice packs to orbit for the first 24 to 48 hours – Surgical repair may be required Blow-out Fracture Follow-up – Review 1 and 2 weeks after trauma, evaluate for persistent diplopia or enophthalmos after acute oedema has subsided – Monitor for associated ocular injuries, eg, orbital cellulitis, angle-recession glaucoma – Gonioscopy and dilated examination performed 3 to 4 weeks after trauma if hyphema or micro-hyphema present TThhyyrrooiidd EEyyee DDiisseeaassee Thyroid Eye Disease (TED) Inflammation and enlargement of extraocular muscles, orbital and periorbital soft tissues Autoimmune mediated phenomenon Most common with hyperthyroidism, though also seen in hypothyroid and euthyroid states Thyroid Eye Disease (TED)
th th Generally presents in 4 – 6 decade Women 2.5-5x more frequently affected Men usually affected more severely
MILD – Foreign Body Sensation – Redness – Tearing
MODERATE – Pressure sensation – Puffiness of eyelids – Worsening ocular surface discomfort
SEVERE – Double Vision – Dyschromatopsia – Visual field loss Signs Eyelid Retraction – Most common and characteristic sign – Upper lid may “lag” behind the globe on down gaze – Lower lid retraction may be present as well Signs Ocular Surface Difficulties – Injection over rectus insertions – Conjunctival Chemosis – Punctate Keratitis – Epiphora Signs Periorbital swelling with pronounced fat herniation
Proptosis Limitation of extraocular motility Diagnostic Studies Thyroid function tests (TFTs) – Patients with TED may have normal TFTs on presentation Orbital ultrasound or Orbital CT – Enlargement of extraocular muscle bellies with normal appearing tendons – Inferior rectus > Medial > Superior > Lateral Management Options MILD -Artificial tears, especially with reading or computer work -Ointment at bedtime Management Options Moderate: – Ramp up daily lubrication – Consider topical steroids – Encourage moisture chamber at bedtime – Consider surgical options Management Options Severe: Double vision, Corneal Exposure, Optic Neuropathy – Maximize lubrication for corneal issues – Short term options: Radiation, Steroids – Definitive Management: 1. Orbital Decompression 2. Strabismus Surgery 3. Eyelid Retraction Repair Uveitis Made Simple Laboratory testing – Medical workup protocols
Medical Laboratory Work-Up Indications Bilateral Recurrent Chronic Unresponsive to treatment Posterior uveitis Pediatric uveitis (under age 15) Medical Laboratory Work-Up Pediatric - standard tests – Erythrocyte sedimentation rate (ESR) – Antinuclear antibody (ANA) – ELISA or IgG/IgM for toxoplasmosis – ELISA or IgG/IgM for lyme – FTA-ABS – VDRL or RPR Medical Laboratory Work-Up Pediatric – TORCH if suspect infection or have posterior segment involvement TORCH Workup – Toxoplasmosis – Other (Syphilis, Lyme) – Rubella – Cytomegalovirus (CMV) – Herpes simplex (HSV) Medical Laboratory Work-Up Adult - standard tests – Complete blood count (CBC) with differential – Erythrocyte sedimentation rate (ESR) – Antinuclear antibody (ANA) – FTA-ABS – RPR or VDRL – Lyme ELISA or IgG/IgM – PPD – Chest X-ray
Medical Laboratory Work-Up Adult - additional tests to consider depending on medical history & symptoms – Angiotension converting enzyme (ACE) – C Reactive Protein (CRP) – Lysozyme – HLA-B27 – Rheumatoid Factor – ELISA or IgG/IgM for Toxoplasmosis – S-I Joint X-ray Medical Laboratory Work-Up Standard test panel designed to detect some of the more commonly related systemic diseases May add or substitute tests at clinician’s discretion Should design test strategy based on suspected diseases, not just order every possible test Unless patient has pulmonary symptoms, may delay chest x-ray until receive the results from other tests • Need to evaluate both patient’s symptoms and laboratory values
Medical Laboratory Work-Up Medical Laboratory Work-Up Medical Laboratory Work-Up Disease – Test Relationships – Rheumatoid arthritis (ANA, ESR, CRP, RF, HLA-B27) – Systemic lupus erythematosus (ANA, CRP, ESR) – Giant cell arteritis (ESR) – Ankylosing spondylitis (S-I joint X-ray, HLA-B27) – Inflammatory bowel (HLA-B27) – Reiter’s syndrome (HLA-B27, joint X-rays) – Syphilis (FTA-ABS, VDRL or RPR) Medical Laboratory Work-Up Disease – Test Relationships – Sarcoidosis (ACE, chest X-ray, serum lysozyme, Gallium scan, biopsy) – Tuberculosis (PPD, chest X-ray) – Lyme disease (ELISA, IFA, IgG/IgM) – Toxoplasmosis (ELISA, IFA, IgG/IgM) – Toxocaris (ELISA, IgG/IgM) – Histoplasmosis (no accurate tests) – Herpes simplex (viral cultures, IgG/IgM) Medical Laboratory Work-Up Disease – Test Relationships – Varicella-Zoster (IgG/IgM) – Allergy (skin test, immunoglobulin levels) – HIV/AIDS (ELISA, western blot) – Behcet’s disease (HLA-B5) – Vogt-Kayangi-Harada syndrome (HLA-DR4) Augmentiin Amoxaciilllliin/Cllavaullanate Broad spectrum penicillin (Staph, Strep, Hemophilus Effective against penicillinase producers-clavulanate blocks penicillinase@@@ High therapeutic index Bacteriocidal Low GI side-efffects Safe in pregnancy Watch out for allergy Cheap***