Josh Johnston, O.D., F.A.A.O. Clinical Director/Residency ... · PDF fileClinical...

RedEyes:It'sJustConjunctivitis...OrIsIt?

JoshJohnston,O.D.,F.A.A.O.ClinicalDirector/ResidencyDirectorGeorgiaEyePartners

*  Alcon*  Allergan*  BioTissue*  Shire*  J&J*  Founder-OculusConsultingPartners*  ContributingEditor-OptometricManagement

Disclosures

Optometry:PrimaryEyeCareProviders

Whosee’syourpatients?

*  PCP’s*  UrgentCare

*  Pediatrician

*  PA

PracticeGrowthOpportunity

*  Medicaleyeserviceshelpbringinpatients*  Leadstoincreasedspectaclesales*  Enhancescontactlenscare*  Patientretention=increasedrevenue*  Greaterwordofmouth(referrals)*  Greateroverallgrowthinallareas(optical,medical,CL's)

Cases

Wewillreviewcommonanduncommoncausesof“redeyes”commonlyseeninpracticeEtiology:*  Infectious*  Inflammatory*  Immune*  Idiopathic*  Allergic*  Environmental*  Other

“Common”RedEyes

Episcleritisvs.Scleritis

Scleritis

MGD

MGDandNewTreatmentOptions:BBL/IPL

DemodexDiagnosis

*  Lashepilation,examinelidmargin*  Viewlashunderlightmicroscopetoconfirmmites

*  Tx:Inofficeandhome*  Incidenceofinfestationincreaseswithage*  84percentofthepopulationatage60*  100percentofthepopulationolderthan70yearsofage

Conjunctivitis

Allergic?Bacterial?Viral?-  OTCvsRX?-  ATs-  Coolcompress-  Topicalsteroids-  Nasalsprays-  Oralmeds

ChallengingCases

*  23yearoldfemaleCaucasian*  Recentlymarried(2014)*  Symptoms:severeocularpainOS>OD,ocularhyperemia

OSx5daysandnowOD,lidswelling,rasharoundlids,scalp,andface*  Sorethroat,febrile,earinfection,nasalcongestion*  (+)Hxofvaricella-zosterasachild*  (+)Hxofectodermaldysplasia*  TakingBactrimPOandAugmentinPO

Case#1:TheNewBride

*  Vesiclesfromforeheadtochin*  Bilateral*  Eyelidsswollenshut

*  Getagoodlookatthecornea!*  Thisphotowasthebettereye!

*  Cornealcultures•  Sensitivity/Specificity?Cost?Efficient?

*  Cornealsensitivity-cottonwisptest*  Futurepointofcarediagnostics?Differential?

Testing

Differential:

*  Pseudodentrites-HZV*  HSV-terminalendbulbs*  Healingepidefect*  Recurrenterosions*  Acanthomoeba*  Neurotropiccornea*  CLwearer

HSVTreatment

*  Valtrex500MGTIDPO*  Zirgan5x/dOU*  D/CBactrim,continue

Augmentin*  PolytrimQIDOU-

prophylaxis*  CyclogylTIDOU*  Tylenol#3PO*  PCP-immunestatus?

TestingDone:*  Slitlampphotos*  Cornealcultures/scraping

*  OnlyworksoncellsinfectedwithHSV*  ProdrugthatgetsphosphorylatedtoganciclovirtriphosphatebythymidinekinaseinhibitingDNApolymerase*  Nontoxic*  Lesssideeffects

Ganciclovir

*  Addphotos

ChronicDisease(3/16)

HSVKeratitis:TypicalPresentation?

HSV

*  Swollenepithelialborders*  Branchedlineardendriticulcerscontainactivevirus*  Atypicalappearance:

-geographiculcer-largedendriticulcers-stromalkeratitis-disciform endotheliitis

Case #2 72y/oAAF-1wkhx“shingles”c/odec.VaOS.Valtrex1gramTIDPO

Va:20/30OD,20/100OS

HZO

•  Valtrex1GramTIDPO

•  Tobradexophungbid

•  ConsidertopicalAbperiorbital

•  DurezolBID/PFTID•  Zirgan5/Day

“Pseudo-dendrites”v.“Dendrites”

Pseudodendrites:Treebranchesw/oterminalendbulbs.

Dendrites:Treebrancheswithterminalendbulbs.

Case#3

*  Diagnosis:HSVstromalkeratitis*  TxwithZirgan5/day,Valtrex500mgTIDPO,PredForteTID*  CTLwearer

InfectiousKeratitis

*  Steroidinducedbacterialkeratitis*  *****CTLwearer******  Presentedtouswithbacterialulcer*  Tx:BesivanceQ1,PolytrimQID,PolysporinungQHS,*  Afterculturescameback,switchedtofortifiedVancomycinwithBesivance

InfectiousKeratitis

InfectiousKeratitis

*  Prokeraleftinplaceuntilcompletelydissolved*  Completelyhealedepithelium*  Continueduseofvanco&BesivancewithProkera

*  44yearoldcontactlenswearerpresented3/29/2015toanoutsideclinicwithblurredvisionandpainOS*  DocumentedAssessment3/29:cornealabrasionwithoutevidenceofinfection*  DocumentedPlan3/29:*  PrednisoloneAcetate1%QID*  Returnin10days

Case#4

*  1weeklater,presentstoemergencydepartmentforasecondopinion-“myeyeseemsworse…”*  ERdoctorspokewithcornealspecialist*  ERdoc:“Itlooksprettybad”*  Steroidsdiscontinuedandbesifloxacinq1hrinitiated*  FollowupASAPinclinic

*  BCVA:LP*  Extensivemucopurulentdischarge*  8.5mm‘soupy’cornealulcerextendingnearlytoinferiorlimbus*  Irishemorrhage*  Flatanteriorchamber*  Seidel(+)

•  Gramstain:Gm-rodsoxidase+

•  Cxconfirms:PseudomonasAeruginosa

•  Perforatedcornealulcer-immediatePKP

• 

*  Besifloxacinq1hr*  PolytrimQID*  CiloxinointmentqHS*  Oralciprofloxacin*  PredForteQID*  ProlensaqDay*  CyclopentolateTID

Treatment

Pseudomonas

Pseudomonas

Pseudomonas

*  Rapid,extensiveinflammation*  Eventualsurgicalintervention*  Commoninhabitantofsoil,

waterandvegetation*  Signs:Grayish-whiteinfiltratew/

anoverlyingepithelialdefect,veryinflamedeye,significantconjunctival,anteriorchamberreaction

*  PseudomonaskeratitisisthemostcommonCTLrelatedinfection

*  Symptoms:acuteonsetofsignificantpain,photophobia,decreasedVa

*  Tx:BroadspectrumfluoroQ30,fortifiedGram-negativeantibiotics(e.g.,tobramycin/gentamycin)

*  Mostcommoncauseofinfectiouskeratitis*  Red,painfuleye*  Typicallysingleareaofulceration*  Mayhavelidswelling,mucopurulentdischarge*  Mosthaverapid(24to48hours)onset

BacterialKeratitis

•  Resistanceaseriousconcern-thinkMRSAwithnursinghome/hospital/healthcareexposure,immunosuppression,ornon-responsivetotreatment.

•  Tx:BesivanceQ30•  Considerpolytrimor

vancomycin.

StaphAureus

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The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.

*  Immunemediatedprocessfromstaphfoundonlids*  Mayhaveulcerationoversterileinfiltrates*  Mayhavesecondaryinfectionofthisulceration*  Treatment:antibioticointmentwithgrampositivecoverage+steroidtolidmargins+lidhygienew/hypochlorousacid*  Tobramycin+dexamethasone*  ConsiderMRSAriskfactors

StaphMarginalKeratitis

Acanthamoeba

*  Free-livingprotozoaActive:trophozoitesDormant:double-walledcysts—veryresistant

*  Riskfactors:contactlenswear(80%),ocularexposuretouncholorinated/unsalinatedwaterespeciallyw/contactwear,trauma

*  Extremepain,exquisitephotophobia,decreasedvision,injection

*  Easilymistakenforbacterialorviral(firstsignoftendendritic),butwon’trespond

Acanthamoeba

*  Patientpresentsearlywithirregular,disruptedepithelium*  Punctateerosions*  Pseudodendriteformation*  Smallinfiltrates*  Oftenmistakenforherpessimplex*  Delayeddiagnosisistypical,avg.6weeks

Acanthamoeba

*  Painisdisproportionatetoclinicalpresentation*  Radialperineuritis*  Subepithelialinfiltratesalongradialcornealnerves

Acanthamoeba:EarlyStages

*  Ringinfiltrate*  Seeninonly6%ofearlycases*  Seeninonly16%oflatecases*  Hypopyon*  Progressivecornealthinning*  Riskofperforation

Acanthamoeba:LateStages

Acanthamoeba

*  Latefinding:denseorringinfiltrate*  Treatment

*Biguanide:PHMB0.02%everyhour*Diamide:Brolene0.1%(notcommonlyavailable)*Neomycinhassomebenefit(notmonotherapy)*Consideradjunctiveoralketoconazole*  MayrequirePKP

*  Mayhavefeatherybordersorsatellitelesions……ormayresemblebacterial*  Considerwithorganic-traumariskfactors,intact

epitheliumoverulcer,orminimaldischargecomparedtolesion*  Timecourse,gramstain,andculturearekeyto

differentiate*  Deeporscleralinvolvementisserious!*  Treatment:natamycin(Fusarium)orvoriconazole(Candida)

*  Longdurationoftreatment

FungalKeratitis

*  Broadspectruminitialcoverage:Moxifloxacin,Besifloxacin,orGatifloxacinq1-2hrswhileawake

*  Broadspectruminitial/advancedcoverage:Fortifiedvancomycin(25mg/mL)+fortifiedtobramycin(14mg/mL),potentiallyplusafluoroquinolone

*  Culturewhenappropriate,agentscustomizedtotheorganismandit’ssensitivities

*  Fungalwillrequireantifungalagent;typicallyslow-growingsoinitialantibacterialtreatmentinanunclearcaseisreasonable

*  Acanthomoebarequiresspecializedagentsandearlydifferentiationmakesabigdifferenceinoutcomes

KeratitisGeneralRecommendations

*  Cycloplegia(especiallyif+ACreactiontoreducesynechiae)*  Bewareresistance.MRSAisontherise!Polytrimgood;

fortifiedvancomycinbetter.Pseudomonascanberesistanttofluoroquinolones;considerdouble-coverageifpoorlyresponsive.*  Cornealabrasionsshouldbeprescribedantibioticsto

preventulceration*  Withclosefollowup&appropriateantibiotics,may

considerbandagecontactlensesinabrasions*  Donotpatchabrasionsincontactlenswearers,andbe

cautiouspatchinganyabrasion

KeratitisRecommendations

Rare..UnlessIt’sInYourChair

*  38Y/OAAFemale*  BlurredvisionODX3years*  SeverepainODX2weeks*  DecreasedvisionODX2weeks*  HxofPKPOSforacornealproblem*  WastoldshewasunabletowearCLsorSrx

Case#5

Case#5

*  ChronicdischargeinamOU*  Admitsto“cleaning”eyesOU*  PreviousdiagnosisofeyeinfectionOU*  NoHxofCLwear*  NoHxofcoldsores*  Obese*  (+)C-papuseQHS

Case#6

Case#6

*  RetinalDetachments-Why?*  DryEye*  C-Papuse*  Lagophthalmos/Microlagophthalmos*  Pinguecula/pterygium*  Systemic

Othercasues:

*  JoshJohnston,O.D.,F.A.A.O.*  Josh@Oculusocp.com

Thanks!