our number one mission as eye docs: stomp out pink eye ...€¦ · an excellent method of self...
TRANSCRIPT
Slide 1
Red Eye Roundup
Paul C. Ajamian, O.D.
London 2013
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 2 Our Number One Mission as Eye Docs: Stomp out Pink Eye!
Doctor, do I have the Pink Eye?
How should I know, I
am looking in your ear!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 3 I’ve Got The
PINK EYE!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 4 Red Eyes: Caveat #1
• They are fun and challenging
• Take them seriously, for they can be very debilitating to patients and can signal a systemic disorder
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 5 Caveat #2
• The treatment is easy: anyone can use the “shotgun” approach and be successful 90 % of the time
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 6 Caveat #2
• It is the methodical evaluation and proper differential diagnosis that is far more difficult
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 7 Caveat #3
• Don’t make the patient’s condition fit the diagnosis!
• Take an open ended history…don’t “fill in the blanks”
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 8 “So, you’re eyes are really itchy, aren’t they!”
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 9 Caveat #4
• Just because they have a red eye does not mean they don’t have something else
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 10 The Case of the “Foreign Body”
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 11 So………………..
• Do a methodical exam on everyone
• Get at least a quick direct scope view of the fundus
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 12 Caveat #5 A
• Get the big picture/be a good observer
– look at face, distribution of injection, swelling
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 13 Caveat #5 B
• Check for pre-auricular nodes
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 14 Caveat #5 C
• Evert lids
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 15 Differential Diagnosis
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 16 The “Common” Red Eye
• Chronic:
Staph Lid Disease, Dry Eye
• Acute:
EKC, Bacterial, Iritis
_________________________________
__
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 17 The Contact Lens Induced Red Eye
• Corneal Infiltrates
• Infectious Ulcers
• GPC
• Solution Allergies
• Acanthamoeba
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 18 Sector Inflammatory Red Eye
• Conjunctival Abrasion
• Episcleritis
• Scleritis
• Inflamed Pinguecula
• Pterygium
• Phlectenule
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 19 Allergic Red Eye
• Seasonal or Hayfever Conjunctivitis
• Vernal
• Atopic
• Medicamentosa (toxicity)
• Neomycin
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 20 Sexually Transmitted Red Eye
• Chlamydia
• Herpes
• Neisseria
• Syphilis
• Lid Lice
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 21 Miscellaneous
• Bullous Keratopathy
• Angle Closure
• Fuch’s Heterochromic Iridocyclitis
• Posner Shlossman Syndrome
• SLK
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 22 Bacterial Conjunctivitis
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 23 Bacterial Conjunctivitis
• Chronic Staph…very common
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 24 Acute Mucopurulent rare
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 25 Blepharitis
• Anterior
– debris on lids
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 26 Blepharitis
• Posterior
– meibomian stasis, tylosis, thickening and vascularization of lid margins, madarosis
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 27 Blepharitis
• Symptoms:
– itching
– burning
– FB sensation
– matter in corners in am
– red rimmed lids
– intolerance to CL’s
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 28 Staph: Complications
• Staining, usually lower third
• Staph hypersensitivity reaction
– Chemosis, staining, neo, injection out of proportion with lid condition
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 29
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 30 Staph: Complications
• Vascularization
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 31 Staph: Complications
• Marginal Infiltrates
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 32 Staph: Complications
• Ulcers
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 33 The Extended Nightmare
• 30 WM smoker
• Silicone hydrogels 1 week wear
• Nasty lids with blepharitis, 4+ meibomian gland dysfunction
• Wakes up Sunday am with a red eye
• Sees OD on Monday
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 34
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 35 Day 1
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 36 Management
• Fortified Vancomycin (25mg/ml) and Tobramycin (14mg/ml)
• Fourth generation fluoroquinolones are good. but not good enough for this type of central ulcer
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 37 2 weeks later
• HM vision all week
• Add Pred Forte tid on Thursday, marked improvement by Monday
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 38
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 39 Take Home Message
• Clean up the lids of bleph patients BEFORE you fit them with lenses
• Even silicone hydrogels can cause problems, especially in males under 30 who smoke and don’t wash their hands
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 40
Check out the lid margins!
Ulcer vs Infiltrate?
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 41 Walmart Garden Girl
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 42 Treatment
• Along with fortified antibiotics, don’t be afraid to add Natamycin or Amphotericin qhourly to the mix
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 43 Get Aggressive Early With Suspicious Ulcers
• Don’t be afraid to go to fortifieds first!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 44 Think Staph is always easy to dx?
• Think again!
• 39 WF
• 6 week hx of bilateral red eyes R>>L with swollen lids
• GP: 2 refills of Tobrex
• OD 1: Tobradex
• OD 2: Sjogren’s Synd
• OD 3: Allergic conjunc
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 45
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 46 Any thoughts?
• CSBLD
• Hair in the RE is not helping matters
• Think about the hair with recurrent allergic conjunctivitis and allergies in general
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 47 Tx:
• Trim hair
• Wash hair more frequently
• Lid scrubs/polysporin ung
• NP Tears
• RV 2 weeks…..marked improvement
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 48 Yet another example….
• 33 BF with a history of multiple red eye episodes x 6 years
• Drops help temporarily
• Now vision dropping with burning, itchy lids
• We were her 4th eye consult in as many months
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 49 Staph Lid Disease: Management
• Lid scrubs
– Baby shampoo, with either swabs or washcloth
– Ocusoft Lid Scrub Pads
– Dandruff shampoo
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 50
• Warm compresses
• Antibiotic or steroid/antibiotic ointment
• If you think a drop is necessary, use the fourth generation fluoroquinolones!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 51 Staph Lid Disease: Management
• Steroid antibiotic drop for surface disease
• Treat concomitant dry eye
• Education critical– demonstrate scrubs to
patient and relatives
– handout
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 52 “Newer” Option
• Azasite
• Viscous, rub into lids at night after lid scrubs
• Also having good results with incipient chalazions
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 53
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 54 Lid Scrub Handout
• You have been diagnosed as having BLEPHARITIS, a common infection of the margins of the eyelids. Typical symptoms include redness, mucous in the corners of the eyes on awakening, burning, itching, and general irritation.
• It is a chronic condition, meaning that one treatment will not eliminate it! It must be taken care of on a regular basis, especially if you are a contact lens wearer, so that more serious infections do not occur.
• An excellent method of self treatment is to use Lid Scrub Pads. These are called Eye Scrub or Ocusoft pads and are available over the counter. Simply take a pad each night at bedtime, close one eye at a time, and gently clean along the lid margins for 20 to 30 seconds. Turn the pad over and repeat for the other eye. Do this at least________times per week. Continue doing it indefinitely, so that the condition and its complications will not return.
• If your condition is more severe, an antibiotic ointment will be prescribed. Apply the ointment to the lids after scrubbing, each night for the first ____weeks and then _____ a week thereafter.
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 55 Case 1: Compliance Critical
• 41 WF
• Longstanding hx of blepharitis, red eyes, styes
• Seen last by us in ’97, instructed re: lid hygiene numerous times
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 56
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 57 Case 1
• On questioning, does lid scrubs “once in a while” only, because of EW contacts
• Wants to know if there are any “new ways to do lid scrubs”
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 58 Treatment
• Reinstruct lid scrubs using pads
• Suggest DW lenses
• Tobradex ung and compresses
• Oral antibiotics if no resolution in two days
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 59 Pearl
• Most patients are non-compliant with lid hygiene, so stay with it!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 60 Case 2: Flop and Fish
• 55 WM attorney
• 3 month hx of red eyes OS >>OD
• Seen 3 OD’s and an MD….no relief from symptoms of mucous in eyes, irritation and redness
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 61
• Significantly injected eyes, with 4+ bleph and vessels into cornea/spk
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 62 Lids as shown with 3+ papillary response on eversion
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 63 Therapy
• Antibiotic/lid scrubs
• Topical steroid and NP tears
• He called dermatologist for refill of oral antibiotic and his brother the plastic surgeon all while I was writing my impression and plan!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 64 Your dx?
• Blepharitis
• Floppy Lid Syndrome
• Mucous Fishing Syndrome
• Three diseases in one!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 65 Floppy Lid Syndrome
• Unilateral or bilateral
• 35-65 yo males, often obese
• Soft rubbery tarsus which spontaneously everts
• Often with history of sleep apnea
• Secondary GPC, SPK from exposure
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 66 Management
• Temporary: Lid taping or shield at bedtime
• Permanent: Surgery
• Steroid antibiotic for GPC
• Tears for exposure/watch for medicamentosa !
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 67 Mucous Fishing Syndrome
• Triggered by any condition that creates mucous
• Must ask if patient is manually removing from eye
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 68
Damage to Goblet Cells =
More Mucous
Initial Red Eye or Irritation
Causes Mucous Production
Patient Removes
Mucous from Eye
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 69
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 70 Management
• Treat underlying problem
– staph lid disease
– GPC, dry eye, floppy lid syndrome, etc.
• Stop fishing!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 71 Other Complications of Staph
• Concretions
– usually only problematic if on upper lid
– can be “needled” out
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 72
• Chalazions
– Biopsy if recurrent to r/o sebaceous cell CA
• Preseptal Cellulitis
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 73 Other Complications of Staph
• Dry Eye
• Phlectenules
• Descemetocoeles
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 74 Questions?
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 75 Viral Conjunctivitis
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 76 Viral Conjunctivitis
• Differential Diagnosis:
– USUALLY FOLLICULAR
• Acute: Adenovirus, Thygeson’s, Herpes
• Chronic: Chlamydia, Medicamentosa
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 77 Case 1
• 42 yo WM with 10 day hx of swollen right lid, then 7 days later left lid
• Seen by military MD, dx’ed orbital cellulitis
• Admitted to hospital, started on oral antibiotics
• cc: right side of face tender, swollen lids, and vision starting to drop
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 78
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 79 Dx: Adenoviral Conjunctivitis
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 80 Case 2
• 33 HM
• Presented on Monday with a hx of a FB sensation OS since Saturday
• Lid swelling noted Sunday
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 81 Case 2
• VA 20/20
• Corneas clear
• + PAN OS
• Pseudomembranes on lid eversion
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 82 Case 2
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 83 Speaking of pseudomembranes….
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 84 Case 3
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 85 Case 3
• 38 WM
• 16 yo babysitter had “pink eye” but “I never touched her”
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 86 Findings
• Watery discharge
• Follicular response
• Occasional hemorrhagic component
• Swollen lids
• Chemosis
• Pseudomembranes
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 87
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 88 Corneal Findings
• Microcysts early
• Subepithelial infiltrates day 7 - 10
• Occasional filamentary keratitis, SPK
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 89
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 90 Can you confirm that it’s viral?
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 91 Transmission
• Treat as contagious for 10 days
• Virus remains viable on contacted surfaces for up to two weeks
• Proper hygiene precautions, gloves, no tonometry, hand washing/change linens to prevent spread to family/friends
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 92 Management
• Education/Support
• Occasionally a friendly second opinion
• Bandage lens
• Tears
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 93 Management
• Steroids only if:
1. Pseudomembrane formation
2. Infiltrates on visual axis
3. Or if the patient happens to be….
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 94 YOU!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 95 Thygeson’s SPK
• Characteristic looking corneal lesions
• Unilateral or bilateral
• Off and on course for several years
• Responds very well to topical steroids
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 96 Case Report
• 31 WF
• Daughter of O.D.
• 1 year history of problems with contacts
• Sees Dad, notes infiltrates OU
• NI with tears, allergy drop or antibiotic
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 97
• Bilateral raised epithelial lesions noted OD<OS
• VA 20/20 OD, 20/25+2 OS
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 98 Eyes quiet = Thygeson’s!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 99 Herpes Simplex
• Primary (lids) or secondary (dendritic)
• Dendrites can affect cornea OR conjunctiva
• Unilateral 98% of time
• Type I or II
– I: ocular, oral, URI, CNS
– II: genital
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 100 Herpes Simplex
• Epithelial Keratitis: Active Virus
– Punctate
– Dendritic
– Geographic
• Stromal (Disciform) Disease: Autoimmune
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 101 Various Presentations
• Unusual keratitis? Think herpetic!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 102 Clinical Pearls
• Always think Herpes if corneal lesions seen
• Look for accompanying iritis
• Check corneal sensitivity
• Ask about cold sores, fever blisters
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 103 Previous Management
• Viroptic (Trifluridine) 1%
• Dosage: every 2 hours, total of 8 or 9 x/day
• Tapered after 5 days
• Maximum time on drug 21 days
• Watch for toxicity
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 104 New Management: Virgan (Zirgan)
• 1 drop 5x/day until ulcer “heals”
• Then 1 drop tid for 7 days
• 5 gram tube
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 105 Management
• Keep cornea lubricated
• Steroids later in the course of healing
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 106 Case 1
• 72 yo male with pancreatic cancer
• 5 weeks after chemotherapy develops red right eye
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 107 Case 1
• Lesion healed well….to a point
• Then steroid added
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 108 Case 1
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 109 Caution!
• What looks like a delicate dendrite can turn into a large ghost dendrite and scar
• Be careful of visual axis lesions!
• May want to get corneal specialist involved
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 110
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 111 Case 2
• 61 WM Optometrist
• Red OS x 8 days
• Was traveling and saw no one
• Self medicated with Tobradex
• Caused plant to grow out of his left ear
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 112 Dx: HSV Keratitis
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 113 Recurrence Rate
• HEDS Study 32%
• With 800 mg oral acyclovir qd, drops to 19%
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 114
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 115
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 116 Stretch Time!
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________