CornealCorneal GrandGrand RoundsRounds
Dr.Paul Karpecki Corneal Services and Ocular Disease Research Koffler Vision Group y 68 y.o. Caucasian female y Complains of photophobia and blurred vision y As well as a headache over right eye for 2 days
Case History yGrade 2- injection: yIrregular SPK and staining yAC: grade 3 cell & flare
Slit lamp exam: Diagnosis?? y______y Nearly 1 Million Americans develop ______each year y ______accounts for up to 25% of presenting cases y Over ___% incur ocular damage
______y Lesion on the tip of the nose y Nasociliary branch of ophthalmic division of trigeminal nerve (V) y Nasal means possibly ciliary (ocular) involvement
______Sign: Ocular findings:
y ______y ______y ______y ______y ______y ______y ______According to a study by Thean what was the most common complication associated with HZO?
A. Iritis B. Optic neuritis
C. Neurotrophic D. Scleritis keratitis y Most common and most often overlooked ocular complication (43%) y Highly elevated IOP y Study by Thean, Hall & Stawall -clinical Ophthalmology Dec 2001 y 56% of patients developed glaucoma!!
Iridocyclitis and HZO Treatment: Iridocyclitis
y Pred Acetate 1% q1 or q2h y Durezol (Difluprednate) 0.05% y Lotemax Long term y Cycloplegia ◦ Homatropine 5% bid ◦ Cyclopentolate 1% bid Six Rules of Iritis Management
y ______y ______y ______y ______y ______y ______Masking Scheme
y Patients were each given two bottles: Bottle A and Bottle B y Each patient received 8 drops every day y In the Durezol group Bottle A contained Durezol and Bottle B contained vehicle y In the Pred Forte group, Bottle A contained Pred Forte and Bottle B contained Pred Forte Mean Score at Baseline Durezol=48.7 Pred Forte=44.5
Percent Reduction in Mean Pain Score from Baseline Photophobia, Mean change from baseline
Mean score at baseline Durezol 60.1 Pred Forte 50.9 Also added medication to lower the IOP
y Diamox 500 mg (non-sequels) after asking about sulfa allergies and kidney problems y Beta-blocker gtts (after asking about heart rate and breathing problems) y Iopidine/Alphagan Treatment:
y ______mg 5x/day y Famvir 500 mg 3x/day or Valaciclovir 1000 mg 3x/day y Advantages: ◦ Easier to take 3x Vs. 5x ◦ Decreased post-herpetic neuralgia, faster resolution of patient (Ormrod - Drugs June 2000) Treatment:
y When should you begin therapy?
y Prior to ___ hours proven for Acyclovir (HE Kaufman) y Not as critical for Valacyclovir or Famvir* (Ormrod) Treatment:
y Duration?
y __ days for most patients although newer studies (Zaal - Am J or Ophthal. Jan 2001) suggest y __ days for patients over age 66 due to shedding y Live attenuated zoster vaccine y Indicated for patients above age 60 who had chicken box as a child but have not had shingles y Doesn’t work in 100% of cases and decreased effect with age
New Vaccine: ______y In the Shingles Prevention Study 38,000 patients 60 and older were enrolled y 51.3% reduction of herpes zoster y 61.1% reduction in the severity of herpes zoster y 66.5% reduction in the incidence of post-herpetic neuralgia
New Vaccine: ______y 58 y.o. Caucasian female y CC: F.B. sensation y Slight blur (20/20 -2) y Epiphora
Case History y SLEx finding - Conjunctivochalasis or trichiasis y Nasolacrimal sac obstruction y Lid Laxity conditions- ectropion y Dry Eye
Epiphora
QuickTime™ and a Motion JPEG OpenDML decompressor are needed to see this picture. TearLab™ Osmolarity Reader & Pens TearLab™ Osmolarity Disposable Chip TearLab™ Tear Collection Tear meniscus height Tear film Non Invasive Break Up Time (NIBUT) with Keratograph
Anterior Membrane Dystrophy (EBMD)
yWeck cell sponge test (Merocil spear)
Additional testing:
87% of all recurrent erosion occurs in what region of the cornea?
A. Superior Cornea B. Central Cornea
C. Inferior Cornea D. Exposure areas of 3:00 and 9:00 Diagnosis:
y______y______Initial Treatments:
y Hyperosmotic agents ◦ Muro 128 ung & gtts y Bandage contact lens ◦ Non-Ionic vs. silicone hydrogel Treatment:
y Daytime meds? y What about hyperosmotic drops? y ______gtts up to QID (Rx only) Which of the following should be avoided in the treatment of RCE?
A. Steroid drops B. Antibiotic drops
C. Oral tetracycline D. Lubricating ointments Treatments:
y Steroids such as Lotemax ◦ Q.I.D. x 2 wks then BID x 6 wks y P.O. Tetracycline ◦ Doxycycline 50 or 20 mg bid x 2 months
◦ Dursun D. et al. Treatment of recalcitrant recurrent corneal erosions with inhibitors of matrix metalloproteinase-9 doxycycline and corticosteroids Ophthal 2001 July Cause of Sliding Epithelium?
y Metalloproteinases which cleave Bowman’s layer below the anchoring system (Hemidesmisones) y Develop through the production of Leukotrienes For how long should RCE therapy be maintained to obtain a clinical cure?
A. 1 week B. 6 weeks
C. 2-4 weeks D. Until the first sign of resolution of symptoms New Treatment for Recalcitrant RCE:
y ______ung x 2 mo y ______drops tid x 2 mo y ______qid x 2 weeks then bid x 6 weeks y ______20 mg PO BID x 2 mo Long Term: y Restasis y Punctal occlusion In the presence of Lid Disease: y AzaSite y Also shown to inhibit MMP-9 Other Options for Recalcitrant Cases:
y Bandage Contact Lens y Stromal Puncture y Phototherapeutic Keratectomy (PTK) 46% of all patients in this study had EBMD
y James Reidy et al. Recurrent erosions of the cornea: epidemiology and treatment. Cornea 2000 Nov; 19(6):767-71
y The remainder had trauma induced causes ◦ Fingernail ◦ Paper cut etc. y 38 y.o. African American Female y Complaint of decreased vision for about 1 week y Longstanding contact lens wearer y Vision seems to be getting worse over last few days y No significant pain y No corneal staining
Case LBV
What test would you perform?
A. Jones Test B. RPS Adenodetector
C. Culture D. Corneal sensitivity Testing???
Cotton Wisp - corneal sensitivity y Trifluoridine - Viroptic q2h y New replacement: Zirgan q2h y PF artificial tears y Follow-up next day, day 3-4, day 7-10
Treatment: Epithelial Involvement Zirgan Zirgan™(Ganciclovir Ophthalmic Gel) 0.15%
Product Background
GAN9-008A Indication and Usage • Zirgan is a topical ophthalmic antiviral that is indicated for the treatment of acute herpetic keratitis (dendritic ulcers).
Zirgan™ (ganciclovir ophthalmic gel) 0.15% Indication Dosage and Administration • The recommended dosing regimen for Zirgan is 1 drop in the affected eye 5 times per day (approximately every 3 hours while awake) until the corneal ulcer heals, and then 1 drop 3 times per day for 7 days.
Zirgan™ (ganciclovir ophthalmic gel) 0.15% Indication Ganciclovir Mechanism of Action
• Penetrates cell infected with the virus • Phosphorylated within the cell to ganciclovir monophosphate by a viral thymidine-kinase – Affinity for thymidine-kinase allows for specificity in its action • Activation continues due to several cell kinases leading to formulation of ganciclovir triphosphate, which: – Inhibits viral DNA polymerase – Incorporates into viral DNA preventing replication y Durezol QID y Pred Forte QID y Cover with PO (400 mg bid) or topical (Zirgan qid)
Treatment: Stromal keratitis y Valtrex 1000mg qd y Patient with Hx stromal keratitis y Children -primary HSV y Toxicity of Viroptic requires lower dosing y Prior to surgery y In all cases of HSV?
When to use Oral Therapy CASE S.P. History
y 26 y.o. Caucasian male y “Foreign body sensation” “light sensitivity” and “eye is red” y Longstanding contact lens wearer y Began this morning
Examination:
y 2+/3- conjunctival injection y Slight lid edema y Pupils normal y Cornea –small peripheral infiltrate, SPK over infiltrate y AC grade 2 cell and flare What appears to be a sterile infiltrate but has an AC reaction...
Begin treatment with ______Follow-up in one day Bacterial Keratitis y Acute onset y Pain y Photophobia y Discharge - mucopurulent y Decreased vision y Excessive tearing, lid edema, blepharospasm
Symptoms y Conjunctival hyperemia and ciliary flush y Lid edema y Tear film debris - thick & cells present y Epithelial defect y Grayish-white stromal infiltrate y AC reaction ◦ from few cells to hypopyon
Signs y Sterile y Infected ◦ Small ◦ Large ◦ Multiple or arcuate ◦ Individual lesions ◦ Mild pain ◦ Pain ◦ No discharge ◦ Discharge ◦ Epithelium intact ◦ Epithelial staining ◦ Elevated ◦ Flat or excavated ◦ AC quiet ◦ AC reaction
Differential Dx Summary Bacterial Keratitis y 1,2,3 Rule: ◦ 1 mm from ______◦ 2 ______(or more) ◦ 3mm or greater in ______y Nosocomial infections y Immuno-compromised patient y Post-surgical
When to culture? Epley KD, Katz HR, Herling I, Lasky JB: Platinum spatula versus Mini-tip Culturette in culturing bacterial keratitis. Cornea 1998;17(1):74-78.
Sensitivity = 83.3%. - Specificity = 100%. Mini-tip Culturette y Fluoroquinolones ◦ Zymar, Vigamox ◦ Now: Besivance y Loading dose q 15 min x 2 hours y Q1h while awake y Q 2h while at night or y Ung – bacitracin or tobramycin
Therapeutic Treatment What it the best form of pain management for a keratitis?
A. Cycloplegia B. Steroids
C. Topical NSAIDs D. Oral NSAID’s y Cycloplege ◦ Homatropine 5% BID ◦ Cyclopentolate 1% BID
Pain Management y Pseudomonas: y Tobramycin 13 mg/ml topical (40mg sci) y Staphylococcus: y Cefazolin 133 mg/ml or Bacitracin 10,000units/ml or Vancomycin 50mg/ml
Fortified Antibiotics y When culture positive result is present: y Decrease meds to only 1 antibiotic y Use medication where sensitivity is shown
Therapeutic Treatment y Other medications for severe keratitis: y Systemic tetracycline y Co-manage with a cornea specialist
Therapeutic Treatment y Besifloxacin 0.05% (Besivance) ◦ Fluoroquinolone FDA approved in July 09 ◦ MRSA and MRSE data is impressive ◦ Uses the DuraSite vehicle allows for full effect with TID dosing ◦ No systemic form of the drug
Anti-bacterial Therapy y 5 year old patient y Significant mucopurulent discharge and red eye y Began 2 days ago not improving
Case MEB y Antibiotic drops qid x 5 – 7 days
y Are you done?
Childhood Conjunctivitis Management? y Antibiotic drops qid x 5 – 7 days y AzaSite or BesiVance y Educate parents on epiphora
y Are you done?
Childhood Conjunctivitis Treatment? Most common cause of bacterial keratitis/conjunctivitis in children?
A. Pseudomonas B. Staphylococcus
C. Strep Pneumo D. Haemophilus influenza y Most common eye disorder in young children y Adult conjunctivitis is typically caused by gram- positive organisms ◦ Staphylococcus aureus and Staphylococcus epidermidis.5 ◦ Conjunctivitis in children is caused by: x nontypeable forms of Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis and adenovirus
Childhood Conjunctivitis y Haemophilus flu bacteria that causes conjunctivitis is the nontypeable form, which is not accounted for by the vaccine.7
H. Flu Vaccine effects? y Rule out trauma y It can alter the management plan ◦ i.e. involve a pediatrician y Increased risk for gram-positive infection, such as MRSA or Streptococcal cellulitis.8
How to effectively manage childhood conjunctivitis: What’s your diagnosis? y One of the most common complications associated with acute bacterial conjunctivitis is preseptal cellulitis y Examine skin and adnexa around the orbit for a discrete reddish sheen y Patients with a preseptal cellulitis often have ethmoidal or maxillary sinus involvement, which results in orbital tenderness.9
How to effectively manage childhood conjunctivitis: What’s your diagnosis? y Fever or general malaise ◦ Purchase a tympanic or forehead thermometer y Acute earache or ear infection ◦ Approximately one-third of all childhood cases are otitis- conjunctivitis syndrome y A notable red sheen around the eyelids ◦ Preseptal cellulitis or cellulitis y Significant purulent rhinorrhea or an upper respiratory infection associated with any fussiness or sleeplessness
When to Refer to a Pediatrician/Pediatric Ophthalmologist: y ______y ______
y Refer to Pediatrician
What other test should you perform on children? y 31 y.o. African American Male y Presents after having seen 2 previous doctors with some improvement but no resolution of red eye y Has been going on for 3-4 months
Patient RSJ y Previous doctors diagnosed bacterial keratitis and tried antibiotics with little response y Lotemax showed improvement but the condition returned after discontinuation even with a slow taper y Patient was referred to our clinic (referral centers have the advantage of previous attempts)
Patient RSJ Clinical findings Small peripheral infiltrates noted What is your diagnosis?
A. CL related B. Adult Inclusion sterile infiltrates conjunctivitis (Chlamydia)
C. EKC or other D. Toxic keratitis viral keratitis What is your recommended treatment?
A. 1000mg B. 5 Day Z-Pack Azithromycin once
C. 100 mg D. Topical AzaSite doxycycline x 3 weeks y 1000 mg Azithromycin (Zithromax) y Four 250 mg tablets all at once y What about a Z-pack? y What about tetracycline?
Treatment: Findings:
y Subepithelial infiltrates y Neovascularization or micropannus y Follicular conjunctivitis y Preauricular lymph node on ipsilateral side y Starts unilateral, if goes long enough could become bilateral THANK YOU