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RedEyes:It'sJustConjunctivitis...OrIsIt?

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

*  Alcon*  Akorn*  Avellino*  Allergan*  BioTissue*  Bruder*  Shire*  Johnson&Johnson*  SunPharma*  Founder-OculusConsultingPartners

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

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Episcleritisvs.Scleritis

Scleritis

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MGD

MGDandNewTreatmentOptions:BBL/IPL

DemodexDiagnosis

*  Lashepilation,examinelidmargin*  Viewlashunderlightmicroscopetoconfirmmites

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

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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

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*  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

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*  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

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“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

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*  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

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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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*  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

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*  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

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*  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

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*  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: