Disclosures
. Dr. Harthan has no direct financial or proprietary interest in any In-Office Care of the Emergency Patient: companies, products or services mentioned in this presentation. Corneal Urgencies and Emergencies . Dr. Harthan speaks, consults and/or does research for: COPE ID: 50189-AS Allergan B+L Jennifer S. Harthan, OD, FAAO, FSLS Chief, Cornea Center for Clinical Excellence Contamac Associate Professor Illinois College of Optometry Metro October 27, 2017 Shire
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Overview Format for Today’s Discussion
. Corneal Abrasions . Presentation of Case . Corneal Erosions . Chemical Injuries . Corneal Lacerations . Review Etiology of Condition . Corneal Foreign Bodies . Corneal Ulcers . Corneal Hydrops . Discuss Management Options . Epidemic Keratoconjunctivitis . Herpes Simplex Virus Dendritic Keratitis . Herpes Zoster Ophthalmicus
Triage Symptoms can point you in the right direction…
. Emergent Situation . Redness Requires immediate action . Discharge Patient is seen same day . Foreign body sensation . Itching . Urgent Situation . Burning Requires patient be seen within 24-36 hours . Lid edema . Photophobia . Pain . Routine Situation . Changes in vision Requires patient to be seen within a few days to a week
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Corneal Abrasion Management Potential Complications
. Antibiotic bid to q2hr . Corneal scarring . Ointment qid . Copious Lubrication . Infectious keratitis . NSAID . Cycloplegic . . Bandage CL Decreased vision . Pressure Patch . Amniotic Membranes . Recurrent erosions . Follow up every 24 hours
90 y/o AAF
2 Recurrent Corneal Erosion (RCE) Etiology and Pathophysiology RCE Acute Management
Repeated episodes of . Previous traumatic corneal abrasion spontaneous superficial . Similar to treatment for erosions abrasions Fingernail, tree branch, paper Antibiotics . Corneal dystrophies Copious Lubrication Anterior basement membrane, Lattice, Granular Cycloplegics . Disturbance to Bowman’s layer NSAIDs (topical vs oral) Bandage CL Follow up every 24 hours to . Age: 24-73 (highest prevalence between 3rd and 4th decade) several days . M=F (slightly higher female) May need to debride . Interval between initial abrasion and first recurrence: 2 days to 16 years If not healing in 24-48 . 10% cases bilateral hours
http://www.reviewofoptometry.com/content/d/cornea/c/53899/
RCE Prophylactic/Long-term Management
. Hypertonic therapy . Amniotic membranes Muro 128 drops or ung qid . Autologous Serum . Doxycycline (50-100 mg bid) . Topical corticosteroids . Vitamin C Lotemax . Surgical . Azasite Anterior stromal puncture . Restasis and punctal plugs Phototherapeutic keratectomy . Bandage and/or scleral lenses (PTK) Superficial keratectomy
**Most require combination therapy***
61 y/o AAF
3 24 y/o AAF Chemical Injuries
. Potentially vision threatening! . No matter how busy… Chemical burns are seen FIRST! . By-pass VA, quickly check pH, then begin immediate irrigation IRRIGATE, IRRIGATE, IRRIGATE!! . Time and action are critical
. Severity is related to: Mild = red eye (good Properties of the chemical prognosis) Area of affected surface Severe = white eye (poor Duration of exposure prognosis)
Etiology Chemical Injuries
. Eye injuries account for 4-7% of workplace injuries . Acidic Burns . Alkali Burns 84% are chemical burns Sulfuric (battery acid), Lime, ammonia, . Incidence hydrofluoric, sodium hydroxide 30 per 10,000 hydrochloric 82-91% men (16-45 y/o) Very damaging- can 90% accidental Usually a self-limiting easily penetrate all Alkali 2x more common burn ocular layers 2/3 occur at work Low pH: 6.9 or lower High pH: 7.1 or greater 10% Intentional Assault
Grading of Severity
. Grade I . Grade II Involves corneal Partial loss of limbal epithelium only stem cells Limbal stem cells Focal limbal ischemia spared <1/3 of limbus No limbal ischemia Hazy cornea Cornea remains clear Anterior segment Prognosis: Excellent structures are visible Prognosis: Good
4 Grading of Severity Chemical Injuries Management
. Grade III . Grade IV . Depends upon severity of burn Total loss of corneal Complete loss of corneal Severe burns (aka significant ischemia, open globe, epithelium epithelium and limbal stem cells periocular open wounds) = immediate external Loss of most limbal stem referral cells Opaque cornea Mild to moderate = treat the problem Stromal haze No view of iris or pupil “Porcelainization” Extensive limbal ischemia > ½ Limbal ischemia Copious irrigation with normal saline for at least 30 Prognosis: Extremely min and repeat every 30 minutes until neutral pH is 1/3 to ½ of limbus poor Prognosis: Guarded reached
Medical Management Goals of Treatment: Reduce Surgical Management Goal: Promote inflammation, promote epithelial revascularization of the regeneration, and prevent corneal limbus, restore limbal stem ulceration cells, re-establish fornices . Double eversion of the upper eyelid . Limbal stem cell . Steroids transplantation . Debridement of necrotic . BCL . Amniotic membrane grafting epithelium . Sclerals . Division of conjunctival bands . Artificial tears . Correction of eyelid . Ascorbic acid (Vitamin C) deformities . Antibiotic ointment . Citric acid . Tarsorrhaphy . Cycloplegic agents . Doxycycline . Penetrating Keratoplasty . Keratoprosthesis Follow up every 24 hours! . Punctal plugs
54 y/o CM
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Potential Complications
. Corneal . Punctal stenosis or occlusion Opacification/Scarring . Limbal stem cell deficiency . Symblepharon . Pannus formation . Dry Eye . Cataracts . Ocular Ischemia . Glaucoma . Corneal Neovascularization . Loss of limbal stem cells – irregular corneal surface
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17 y/o AAF
6 Corneal Lacerations Corneal Lacerations
. Etiology: . Immediate Referral . Small, partial- thickness lacerations may generally be treated as Industrial accidents abrasions with patching therapy . Larger wounds often require immediate surgery Traffic accidents . No ointment should be applied to the eye . Seidel Test Home accidents Positive = full thickness Negative = partial thickness Assault . Fox shield over eye for protection Need to keep anterior chamber intact Traumatic would rupture
29 y/o CM Corneal Foreign Body Removal
. ***Accurate assessment of depth of penetration before removal*** Pupil irregularities, iris tears, transillumination defects, lens opacities, hyphema, shallow A/C, low IOP . Irrigation . Sterile cotton swab or sponge . Spud . Jeweler’s forceps . Needles . Alger brush . May need to remove deeper rust rings at a later date after they have migrated to the surface
7 Corneal Foreign Body Treatment
. After removal of foreign body Measure size of resultant epithelial defect Treat as for corneal abrasion Look for signs of intraocular FB: . Cycloplegic • Corneal . Antibiotic laceration, iris tear, lens opacity, . Bandage contact lens collapsed anterior . Corticosteroids chamber, low IOP After re-epithelialization to reduce scarring . Follow up 24 hours
23 y/o AAF
Corneal Ulcer Corneal Ulcer Etiology
. Bacterial . INFECTION of the cornea by microbes S. aureus S. pneumoniae . Characterized by excavation of the corneal epithelium, Bowman’s, and stroma M. lacunata P. aeruginosa . Infiltration . Necrosis of tissue . Fungal . Ideally all cases should be cultured Fusarium . Realistically… Aspergillus >2mm in size Candida <3mm from visual axis >1/4 corneal depth . Acanthamoeba
8 Corneal Ulcer Risk Factors Corneal Ulcer Signs/Symptoms
. Clinical manifestations . Eyelid disorders . Contact lenses Foreign body sensation . Chronic corneal disease Poor personal hygiene Followed by increasing pain and photophobia . Refractive surgery Contaminated solutions Decreased VA . Blepharitis Lens surface deposits Marked conjunctival hyperemia and inflammation . Chronic lacrimal drainage Non-compliance with Ciliary flush obstruction disinfection Pupillary constriction . Immunosuppression Lens manipulation Mucopurulent discharge . Trauma Corneal hypoxia with Anterior chamber reaction, with or without hypopyon extended wear Ragged, irregular epithelial ulceration with underlying necrotic stromal infiltration and surrounding epithelial edema
Signs in Chronological Order Ulcer Vs. Infiltrate
Enlargement of Progressive • Infiltrate Infiltrate • Enlarging Ulceration • Circum-corneal • Stromal edema hypopyon • Corneal injection • Small perforation hypopyon • Endophthalmitis Epithelial Severe Defect Infiltration
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Corneal Ulcer Treatment
. Discontinue CL wear . Fortified subconjunctival or IV antibiotics . Culture Cefazolin, vancomycin, . Broad spectrum topical gentamycin, tobramycin antibiotic therapy . Cycloplegic Consider loading dose of . Topical corticosteroids antibiotic SCUT study One drop q 5 min for 15-30 . Amniotic Membrane min . PKP One drop q 30-60 min for . CXL? 24 hrs
9 Fungal Keratitis Treatment Acanthamoeba Keratitis Treatment
. Filamentous fungi: Natamycin 5% (Natacyn) q1hr . Topical treatment often includes a combination of agents: (including during sleep) Loading dose (first 1-3 days) Chlorhexidine 0.02% and/or PHMB (polyhexamethylene . Yeast: Amphotericin B 0.15% q5min x 1 hour, then q1hr biguanide) 0.02% Flucytosine orally 150mg/kg/day or topically 1% 1gt AND q30mins to inhibit fungal growth Propamidine isethionate 0.1% (BroleneTM) . No Steroids POSSIBLY INCLUDE Neomycin solution or fluoroquinolone . Consider hospitalization **Natamycin is the only commercially available . All meds q1hr (also during sleep) . Voriconazole antifungal for ophthalmic . Each drug given at the same interval separated by 5 minutes use in the US
Corneal Ulcer
. Follow up every 24 hours . Pain level, inflammation, and size of defect should decrease continually . Taper medications as needed . Refer non-compliant patients and worsening ulcers
25 y/o AAF presented to ER
. CC: “bubble on pupil” OD, x 1 . (-) meds day . PMH: (+)HTN, seasonal . (+) tearing, blurred vision, allergies, developmental eye rubbing disability . (-) pain, photophobia . Decreased VA, longstanding . (-) CL wear
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10 . VAsc: OD 20/400 @ 2 ft OS 20/70-2 . PERRL(-)APD . EOMS: FROM . CVF: Restricted OD FULL OS
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Pachymetry After 3 months of treatment
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Pachymetry after 3 months Corneal Hydrops- Signs & Symptoms
. Decreased vision . Conjunctival Injection . Pain . Corneal Edema . Redness . Break in Descemet’s . Photophobia . Bullae . Epiphora . CL Intolerance . **Underlying Corneal Ectasia
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11 Standard Treatment Regimen Keratoconus and Inflammation?
Topical Antibiotic Prevent infection from ruptured . Keratoconus may be a “quasi-inflammatory” disorder bullae . Tears from keratoconic eyes showed elevated levels of Topical Hypertonic Solution Decrease corneal edema Pro-inflammatory marker IL-6 Pro-inflammatory marker TNFα Tissue degrading MMP-9’s Cycloplegic Pain management . Keratoconus may be due to an imbalance between pro- inflammatory and anti-inflammatory cytokines
Copious Artificial Tears Reduce surface irritation
Why Doxycycline? Why Vitamin C?
. Inhibitor of MMP-9’s . Excellent anti-oxidant . Indirect anti-inflammatory properties properties . Decrease apoptosis of . Beneficial in treatment of corneal tissue recurrent corneal erosions . Decreased scarring when . Promotes corneal healing used both orally and intravenously in cases of infectious keratitis
[email protected] Epidemic Keratoconjunctivitis (EKC) Epidemic Keratoconjunctivitis (EKC) Pathogenesis Clinical Manifestations- Acute Phase
Bilateral in majority of cases Pre-auricular lymphadenopathy . Occurs in two phases Preceded by URI Potential pseudomembrane One week to 10 days after formation Acute inoculation: Corneal involvement Sudden onset of profuse serous Begins unilaterally, then less severe in fellow discharge SPK eye Periorbital pain May appear as early as first or second week Severe follicular conjunctivitis Follows 7-16 day course Virus-infected cells Chemosis May form focal keratitis Sequelae Petechial hemes on palpebrum Moderate to severe eyelid More severe corneal involvement edema
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12 [email protected] Epidemic Keratoconjunctivitis (EKC) Clinical Manifestations- Sequelae phase
Variable course
Subepithelial infiltrates Within 7-14 days after onset of ocular symptoms Early in third week
Variable number, location and density
Variable affect on VA
Delayed hypersensitivity reaction to viral antigen in overlying epithelium.
Immunopathologic response to viral infection of keratocytes in the superficial corneal stroma.
Photo courtesy of Dr. Stephanie Klemencic
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[email protected] [email protected]
**Photophobia and reduced VA from adenoviral subepethelial infiltrates may persist for months to years.**
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[email protected] [email protected] Epidemic Keratoconjunctivitis (EKC) Management
Patient is contagious! Topical NSAID Patient education Cidofovir? (prophylaxis?) Hygiene!!!! Zirgan Discard contact lenses Betadine 5% Sterile Supportive therapy Ophthalmic Prep Peeling of Solution pseudomembrane Cyclosporine A 0.5- Topical corticosteroids 2.0%
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13 [email protected] [email protected] 5% Betadine Ophthalmic Prep Solution
. Used for pre-surgical prep
. Off-label use for moderate to severe EKC
60 second treatment followed by lavage
Pre- and post- treatment with topical NSAID
Topical steroid qid x 4-6 days
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[email protected] Patient Concerns:
. Am I contagious?
. How long am I contagious for?
. Do I need to stay home from work/school?
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Herpetic Eye Disease: Review Herpes Simplex
. HSV eye disease is a wide spectrum of clinical problems. . HSV I . HSV II Oral herpes Genital herpes . Ranges from dermatitis of eyelid, blepharitis of the lid Upper body Lower body margin, conjunctivitis, epithelial keratitis, stromal Affects eye, mouth, skin Less commonly affects the above the waist and eye, but tends to be more keratitis and iritis. respiratory tract severe Less commonly affects Sexual and neonatal genitals transmission Transmission by direct contact
14 Herpes Simplex Herpes Simplex: Dendritic Keratitis
. Can affect anterior to posterior segment! . Symptoms: . Signs: . Corneal aesthesiometry Foreign body sensation Conjunctival hyperemia Side that has herpetic infection will show reduced sensitivity! Increased lacrimation Early SPK that then takes Measurement: Photophobia on dendrite pattern Cochet-Bonnet aethesiometer Pain Branching (dendritic) epithelial lesion Cotton wisp Dental floss Knob-like end bulbs that stain with fluorescein and lissamine green
Herpes Simplex: Dendritic Keratitis Herpetic Eye Disease
. Treatment: Topical antivirals . NEVER PUT A STEROID ON AN ACTIVE DENDRITE Viroptic (Trifluridine) - 9x/day until re-epithelialization; then But put one on just about every other ocular herpetic 5x/day x 7 days sequela Zirgan (Ganciclovir) – 5x/day until re-epithelialization; then tid Disciform keratitis x 7 days Stromal keratitis Oral antiviral as alternative or in conjunction Herpetic iritis Acyclovir 400mg 5x/day Pseudodendrites? Valacyclovir 500mg tid Famciclovir 250mg tid
[email protected] [email protected] Mechanisms of Ocular Involvement
1. Direct viral invasion epithelial keratitis or conjunctivitis
2. Secondary inflammation episcleritis, scleritis, keratitis, uveitis Inflammation and/or degeneration of peripheral nerves, central ganglia or altered CNS signal processing may attribute to PHN
3. Reactivation necrosis and inflammation in ganglia neurotrophic keratitis
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15 [email protected] [email protected] Recurrent Infection: HZO varicella-zoster virus Clinical Manifestation (VZV) Headache, malaise, fever, chills
Neuralgic pain and chicken pox shingles hyperesthesia/edema of (varicella) (herpes zoster) dermatome(s)
Clear vesicle eruption; followed by yellowing and possible scarring
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HZV Dendrites vs. HSV Dendrites True Dendrite Pseudodendrite Herpes Simplex Herpes Zoster . HZV Dendrites: . HSV Dendrites: Grayish-white Branching lesion Raised Flat “Painted on” appearance Terminal end bulbs Coarse and fragmented Stain well centrally with No end bulbs NaFl Stain poorly with NaFl Peripheral cells/ end bulbs Stain well with RB stain with RB/LG “Nummular Keratitis”
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[email protected] Herpes Simplex vs Herpes Zoster Varicella Zoster: Herpes Zoster Ophthalmicus Herpes SIMPLEX Herpes ZOSTER Dermatomal distribution Limited More complete . Management: Dendrite appearance Larger, more branching, Smaller, less branching, Topical antivirals: not effective discrete, delicate pattern, coarse, blunted pattern, more central usually peripheral Oral antivirals: dosage is double that for simplex Best if initiated within 48-72 hours Epithelium Ulcerated Blunted dendrite with slightly Most debilitating sequelae: post-herpectic neuralgia raised edges Each case is individual: i.e. if uveitis, treat uveitis appropriately Ok to use a steroid with End bulbs Present Absent Topical artificial tears pseudodendrites! Scarring of skin Rare Common Topical erythromycin ointment Postherpetic neuralgia Rare Common Can spread over lesions as they crust over
Iris atrophy Rare Common
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16 [email protected] [email protected] Hutchinson’s Sign ***Herpes Antiviral Treatment***
Herpes Simplex Herpes Zoster Acyclovir 400 mg 5x/day PO 800 mg 5x/day PO (Zovirax) Valacyclovir 500 mg TID PO 1000 mg TID PO (Valtrex) Famcyclovir 250 mg TID PO 500 mg TID PO (Famvir)
•Goal: Tx within 72 hours of Sn/Sx to ↓ risk of PHN and risk of ocular complications
•Ideally Tx with prodromal Sn/Sx (tingling, numbness along CN V1 dermatome) to achieve maximum benefit of Tx
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Oral Antivirals Oral Antivirals
. Contraindications: . Effectively treats all expressions of acute herpes simplex disease Caution with renal insufficiency – consult PCP i.e. orals expressed in tears, can treat epithelial HSK . Side effects: Gastric distress . High efficacy and high safety profile Mild nausea Very well tolerated . Notes: Few side effects and little resistance Drink more water while taking antivirals Start within 72 hours for best effect . All clinically perform identically Can also be used to prevent recurrence of stromal disease by approximately Aim to Rx least dosage, usually valacyclovir 50% However, acyclovir is least expensive Acyclovir: 400mg bid x 1 year+ Valacyclovir: 500mg qd x 1 year+ . Note that acyclovir comes as a liquid suspension Kids or adults with difficulty swallowing pills
Herpetic Eye Disease Study: HEDS Herpetic Prophylactic Treatment
. Older HEDS: focused on treatment of active disease No benefit to adding oral acyclovir in stromal keratitis if the patient is Acyclovir 400mg bid already taking topical steroids and antivirals Valacyclovir 500mg qd Topical prednisone is helpful in treating stromal keratitis Famciclovir 250mg qd
. Newer HEDS: focused on prevention of recurrence Oral acyclovir 400mg bid reduced rate of recurrence of ANY form of . All reduce: ocular herpes in the following year by 41% Frequent debilitating recurrences Gives 50% reduction in the recurrence of severe forms of ocular herpes Bilateral involvement If patient already taking trifluridine gives no added benefit in HSV infection in a monocular patient preventing epithelial disease from developing into stromal disease or iritis
17 [email protected] Important Patient Education Varicella Zoster …Questions that may arise Am I contagious? . Primary Infection = Chicken Pox Recommend . Yes Zostavax vaccine to Varivax vaccine . Lesions contain high concentrations of VZV all patients >50 y/o . Spread via contact and airborne route . Can cause primary varicella (chicken pox) in susceptible persons . Secondary Infection = Zoster/Shingles For how long? Zostavax vaccine . Once rash appears until lesions crust . Approximately 14 days
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[email protected] [email protected] Ocular Complications of HZO
. Conjunctivitis . Pupil anomalies (Horner Syndrome, tonic pupil) . Lid scarring . Lipid-filled granulomata . Keratitis nummular, stromal, disciform, mucous plaque, neurotrophic . Episcleritis . Scleritis . Uveitis . Iris atrophy . Cataracts . Glaucoma, secondary to trabeculitis . CN palsies (CNIII most common) . Optic neuritis Make sure to dilate! . Chorioretinitis . Acute retinal necrosis . Progressive outer retinal necrosis Ocular manifestations can occur 4 to 6 days after skin 105 vesicles erupt 106Facial lesions healing/starting to crust
[email protected] [email protected]
Day 7
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• Large corneal abrasion • Corneal edema w/ corneal folds • Sub-conjunctival hemorrhage nasally
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Clinical Pearls
. Thorough history . Symptoms can point you in the right direction Thank You! . Careful examination [email protected] . Treat each case individually Consider newer approaches . Follow up appropriately . Refer as necessary
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