I HAVE RECEIVED HONORARIUM, COMPENSATION, OR SERVE AS AN ADVISOR TO THE FOLLOWING COMPANIES

Transcription

1 FINANCIAL DISCLOSURE FORM DR JACK L. SCHAEFFER The Greatest Anterior Segment Disease and Contact lens complications course ever Jack Schaeffer OD FAAO Paul Karpecki OD FAAO Charlie Ficco OD I HAVE RECEIVED HONORARIUM, COMPENSATION, OR SERVE AS AN ADVISOR TO THE FOLLOWING COMPANIES ALCON ALLERGAN AMO/ABBOTT ARCTIC/DX ATON BAUSCH AND LOMB COOPERVISION ESSILOR ISTA HOYA OPTOVUE OPTOS VISTAKON ZEIS VISION Dilation Vs Optomap The two together delivers a the highest level of Comprehensive Eye Care If you have to choose just one: DILATE, DILATE, DILATE Telephone Consultations 30 YO WF Telephone symptoms: sore upper lid, painful spot on lid Internal Hordeolum?? Ready to Dx on telephone: decided to see the patient Bacterial Conjunctivitis? Extremely Tender Upper lid Upper lid swelling Excessive Mucous production Bacterial Conjunctivitis Orbital Cellulitis? Tx: PO Augmentin PO 875 Mg Bid Ocular Zymaxid OS q 2 h 1

2 Day 2 Facial Pain Headache Fever Referral to PCP, R/O Orbital Cellulitis Dx Severe Sinus infection: Contd Meds PO ( Augmentin) Antibiotic Injection in office Sinus infection Lid swelling with Pain Lid Disease- Infection Keflex 500 Mg BID Cephalexin Bactrim: double strength: BID Trimethoprim/ Sulfamethoxazol Augmetin 875 mg BID Miboflow Hot compress ( Written instructions) MiBoFlow Caniliculitis/Dacryocystitis Keflex 500 Mg BID Cephalexin Bactrim: double strength: BID Trimethoprim/ Sulfamethoxazol Augmetin 875 mg BID Hot compress ( Written instructions) MiBo Flow 2

3 Doctor number 3 Concretions (lithiasis) 68 YO female Pain discomfort 2 years OU OD > OS 3 rd doctor Restasis BID White to yellow nodules superficially buried within and beneath the palpebral conjunctiva Asymptomatic unless enlarge, protrude Pathophysiology- inclusion cysts filled with keratin and epithelial debris- very little calcium Concretions only n=35 Severe Dry Eye 43% 47% TBUT < 10 seconds 51% 60% Concretions + MGD n=15 Haici P et al Dry eye syndrome in patients with conjunctival concretions. Cesk Slov Oftalmol Concretions Management Asymptomatic- neglect (@ 6% become symptomatic Symptomatic Fine tipped forceps delivery 25 ga needle Education R.E. recurrence? We will discuss this later More on Zoster later HZO Elocon Allergic Dermatitis Mometasone Crème Lotemax ung 3

4 Basal Cell 90-95% of malignancies Hair bearing skin M=F LL>MC>UL>LC Rarely metastasizes Recurrence is common Corneal Toxicity Organic Soap splashed in eye Moroccan Oil based soaps Trauma Traumatic Hyphema 48 y. o. b. m. NP Friday at 4:30 pm. Weed eating lawn, just thinking to myself, I should put my goggles on, 2 hrs prior to exam. LEE 5 years Va: CF 5 OD, 20/20 OS Trouble on the glass 26yoM poked in the eye playing basketball Redness, light sensitivity, pain OD VA 20/40- OD 20/30 OS 24 4

5 Assessment 1 ) Conjunctival laceration 2) anterior Uveitis 3) trauma evaluation Cornea Retina ( esp peripheral) Angles OCT yes I said OCT Co management Rules Who is the patients Doctor Control of the patient and the disease process Assessment 1 ) Conjunctival laceration Ocular plastics for suture 2) Trauma / Uveitis Optometry for treatment Sent to Corneal specialist for suture of laceration Cyclogel in-office Besivance q2h OD PF q1h OD beginning at bedtime pm Red Eye Sent to Corneal specialist for suture of laceration Cyclogel in-office Besivance q2h OD PF q1h OD 15 yo M reports trauma OS from tennis ball off volley at the net Severe Pain, photophobia, blurry vision, lid swelling VA sc OD 20/20 OS 20/30 PH

6 Clinical Findings OD WNL What next? OS Small SCH Inferior temporal Diffuse 360 linear abrasions side-to-side Trace cells in AC Cyclo instilled in office BCL applied post-dilation Besivance q2h OS RTC tomorrow Any testing to be done tomorrow? Commotio Retinae Discoloration of outer retina due to photoreceptor outer segment disruption Typically resolves in 4-6 weeks Can affect vision if in the macula Berlin s Edema Just Playing- Lessons Even in cases of straight-forward trauma remember other potential areas of damage A/C Retina Management Fox shield affected eye Cycloplegia (homatropine 2.5%, 5%) Modified bed rest (elevated 45o and no physical activity for 5 days Report any changes immediately 33 Developing a Specialty Practice Cornea Disease 60 y. o. b. f. c/o chronic fbs and Dry Eyes. PMHx: Osteo A and HTN Tx. w/ OTC NSAIDS prn and Lopressor POHx: Punctal plugs x 4, 1 yr. ago, rmvd. Bva: 20/25, 20/25-2 G A T: 12, 10 Hertel : 17mm, 18mm, base98 6

7 SLK Lets look at another case to follow Patient MJP 36 y.o. Caucasian female Referred to clinic for decreased VA OD>OS and corneal irregularity No history of trauma or chemical burns Vision gradually getting worse over the last 1-2 years, OS now decreasing as well Only history is contact lens wear since age Patient MJP VA: 20/60 OD BCVA w/ x /25- OS BCVA w/ DS Pupils normal, FTFC conf fields, normal motilities IOP: 14, 15 Osmolarity: 303 & 305 Patient MJP Lids grade 2 MGD OU Conj grade 1 injection OD, trace OS Cornea haze, neovascularization and SPK OD and mild superior haze and SPK OS AC-D&Q, Lens Clear Posterior Seg - unremarkable SLK Stem Cell Abnormalities FBS, burning, photophobia Females predominate Path. = Mechanical, Inflammatory, local tear deficiency. Tx: BCL, PP, Top. anti-inflammatory agents i. e. steroids or Cyclosporine, autologous serum, surgical. Sahin A, Bozkurt B, Irkec M. Topical cyclosporine a in the treatment of superior limbic keratoconjunctivitis: a long-term followup. Cornea. Feb 2008;27(2): Goto E, Shimmura S, Shimazaki J, et al. of superior limbic keratoconjunctivitis by application of autologous serum. Cornea. Nov 2001;20(8):

8 Loteprednol QID x 2 weeks then BID x 2 weeks OU AT s QID OU Restasis bid :Tid Autologous Serum drops Q2h OU SLK Medical CL Continental Bandage Lens BC, D, PL, DK ABB Concise BC, D, PL , DK Many others TQ Told to discontinue CL OU 44 19yoF Red Eye OD Red Eye x 3 days with no pain, today was the first day with irritation Recently had Staph infection in leg, off antibiotics less than a week ago ( Bactrim) VA sc 20/20- OD 20/25 OS Zylet qid OD RTC 1 day Some improvement over the new few days, but minimal D/c Zylet qid OD, begin Besivance q1h OD Differentials? Pt showed significant improvement, at 1-day follow up Differentials? Herpes Simplex Keratitis Adenovirus Solution Hypersensitvity MRSA Remember staph in fection leg treated with Bactrim Nursing student

9 Whats Next? THYGESSONS Diagnosis 50 Thygessons Possible Thygeson s When all else fails: Thygessons Vs HSV Discontinue ALL meds 52 Thygeson s SPK Described by Phillips Thygeson in 1950 Slightly elevated corneal lesions, minimal staining Usually bilateral, Second to third decade Noted corneal sensitivity decreased but not as severe as herpes Mild conjunctival involvement, worse with exacerbations Appearance similar to EKC described by Fuchs 53 Thygeson s SPK Lesions in basal epithelial layer / Bowman s layer Debris from necrosis / degenerated epi cells Increased Langerhans cell density Part of inflammatory response- Type II 54 Thygeson s SPK : Anecdotal Cyclosporin 2% in olive oil (8 patients) Supratarasal injection triamcinolone (1 case-chronic 6+ years) Trifluridine (6 eyes) PRK in myopic patient had lesions recur in periphery (untreated area) vs central (treated area) Rimexolone 1% for reversing dendritic cell density (4 patients) 55 9

10 Thygeson s SPK Back to the case Steroid Use Loteprednol 0.2%, 0.5% Cyclosporine 0.05% Long Term D/c All meds Lesions healed in 1 week No recurrences since October Plaquenil Keratopathy Vortex Keratopathy or Cornea Verticillata Clinical features: Symptoms: the corneal changes are rarely of any visual significance. Signs: Symmetric, bilateral, whorl-like pattern of powdery, white, yellow or brown corneal epithelial deposits Appears in a vortex fashion in the inferocentral cornea and swirls outwards sparing the limbus Occurs in Fabry's disease and in patients being treated with a variety of drugs including amiodarone, chloroquine, amodiaquine, meperidine, indomethacin, chlorpromazine and tamoxifen. Systemic Disease- Ocular Involvement Ocular Surface Disease Secondary to Systemic Disease Herpes Simplex Herpes Zoster Rheumatoid Arthritis 10

11 HS Blepharitis Systemic Disease- Ocular Involvement Herpes Simplex Case 14 YO male Football player ( Son of evening news Sports anchor) OS Uncomfortable for a few days Peds gave Tobramycin Valcyclovir Zirgan Betadine? Case LBV Diagnosis HSV 38 y.o. African American Female Complaint of decreased vision for about 1 week Longstanding contact lens wearer Vision seems to be getting worse over last few days No significant pain No corneal staining 11

12 35 yo F, my right eye is bothering me Clinical Findings Redness, watering, photophobia x 3 days VA 20/100 PHNI OD, 20/50 OS CL Abuser- overwears, sleeps in lenses, Generic solution OD 3-4+ K folds, (+) central SPK, Stromal haze Circumlimbal injection (-) AC Reaction Pachs 1004 OD Central cornea Punt or Treat? Vigamox q30min Cyclo D/c CL wear RTC tomorrow When to start steroids? Herpes Endotheliitis Stromal Ring Caused from decreased endothelial cell function KPs central Sharp demarcation from affected to non-affected areas Not pathognomonic- CMV New Valacyclovir (Valtrex) 500mg tid po PF q1h OD Continue Vigamox qid OD while cornea not 100% healed Testing??? Cotton Wisp or Dental floss to measure corneal sensitivity 72 12

13 Herpes Simplex Virus (HSV) Endotheliitis HSK/Steroid Cocktail 66 y. o. h. f. C/O 2 wk hx of ache, watery discharge and dec. Va OS worsening sx. Tx by a colleague with Lotemax OU qid x 2 wks. MHx: Neg. OcHx: Ocular Hypertension : Epithelial Involvement In the past: trifluoridine - Viroptic q2h New replacement: Zirgan 5 x per day until ulcer disappears then TID x 1 week PO Valtrex 500mg TID PF artificial tears Follow-up (next day), day 3-4, day 7-10 Zirgan (Ganciclovir Ophthalmic Gel) 0.15% 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. 13

14 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 : Stromal keratitis or Endotheliitis Durezol QID Pred Forte Q2H Cover with PO Acyclovir (400 mg bid) or Valtrex (1000mg QD) or topical (Zirgan TID) When to use Oral Therapy Toxicity of Viroptic requires lower dosing Patient with stromal keratitis Prevention of HSV stromal keratitis Children -primary HSV Prior to surgery In all cases? Trigeminal ganglion suppression Case History 68 y.o. Caucasian female Complains of photophobia and blurred vision As well as a headache over right eye for 2 days Slit lamp exam: Grade 2- injection: Irregular SPK and staining AC: grade 3 cell & flare Herpes Zoster Ophthalmicus 14

15 Herpes Zoster Ocular findings: Nearly 1 Million Americans develop herpes zoster each year HZ ophthalmicus accounts for up to 20% of presenting cases Over 50% incur ocular damage Conjunctivitis/Scleritis Pseudodendrites Neurotrophic keratitis Iritis Glaucoma ION, vein or artery occlusion Nerve Palsy Iridocyclitis and HZO Most common and most often overlooked ocular complication (43%) Highly elevated IOP Study by Thean, Hall & Stawall -clinical Ophthalmology Dec % of patients developed glaucoma!! : Acyclovir 800 mg 5x/day or new to generic: Valtrex 1000mg 3 x/day or Famvir 500 mg 3x/day oradvantages:easier to take 3x Vs. 5xDecreased post-herpetic neuralgia, faster resolution of patient (Ormrod - Drugs June 2000) : : When should you begin therapy? Duration? Prior to 72 hours proven for Acyclovir (HE Kaufman) Not as critical for Valacyclovir or Famvir* (Ormrod) 7 days for most patients although newer studies (Zaal - Am J or Ophthal. Jan 2001) suggest 10 days for patients over age 66 due to shedding 15

16 New Vaccine: Zostavax New Vaccine: Zostavax Live attenuated zoster vaccine Indicated for patients above age 60 who had chicken box as a child but have not had shingles Doesn t work in 100% of cases and decreased effect with age In the Shingles Prevention Study 38,000 patients 60 and older were enrolled 51.3% reduction of herpes zoster 61.1% reduction in the severity of herpes zoster 66.5% reduction in the incidence of post-herpetic neuralgia : Iridocyclitis Check IOP Pred Acetate 1% q1h or q2h or Durezol (Difluprednate) 0.05% with half the dosing Lotemax Long term Cycloplegia Homatropine 5% bid Cyclopentolate 1% bid Typically IOP will go down because of slowing of the ciliary body muscle Can it go up? Trabeculitis HZO case described earlier had an IOP of 56! Gauge Severity to determine if further testing is required When would a systemic work-up be warranted? PS KP s on endothelium Hypopyon Bilateral presentation Recurrent presentation 16

17 Six Initial Tests to Run: 1. CBC with Diff (also check lymph nodes) 2. SED rate 3. HLA-B27 antibody 4. ANA (antinuclear antibody) 5. FTA-ABS (fluorescent treponemal antibody absorption) 6. ACE (angiotensin converting enzyme) HLA-B27 positive antibody: Indicates a systemic predisposition Diseases include but are not limited to: Juvenile rheumatoid arthritis (< age 16) Rheumatoid arthritis Check the patients hand Ask about psoriasis i.e. psoriatic arthritis Ankylosing spondylitis Young men Ask about lower back pain or stiffness Reiter s Disease urethritis, tendonitis and polyarthritis Crohns disease or ulcerative colitis ask about diarrhea and GI problems Treat aggressively Difluprednate Formulation Never start an iritis treatment QID with Pred Forte Must be Q2H or Q1H even for grade 1 Or consider Durezol at 1/2 the dosing of Pred Forte Developed as an emulsion No shaking required BAK-free Uses sorbic acid as a preservative Available in 5 ml bottle The Importance of Cycloplegia 1.Re-establish vascular permeability 2.Prevent synechiae 3.Pain Management Seven Rules of Iritis Management 1. Rule out keratouveitis 2. Check IOP 3. Rule out previous ocular surgery 4. Gauge severity need for systemic work-up 5. Treat AGGRESSIVELY 6. Go beyond AC cell and flare (Restore the Blood- Aqueous Barrier 7. Dilate and examine the posterior segment 17

18 Contact lens peripheral Ulcer ( CLPU) Sterile Infiltrate ( not!) Corneal Ulcer How to treat When to culture When to refer and to whom Demodex Ubiquitous obligatory ectoparasites of man Two forms: D. brevis and D. folliculorum Lifecycle of 14.5 days Negatively phototaxic Move in dark environment, stop with bright ones Lacey N et al. Demodex Mites Commensals, Parasites or Mutualistic Organisms? Dermatology 2011;222: Demodex 84% of patients at 60, 100% over 70 Increased incidence with: Age Immunocompromised Skin disorders (Rosacea) Eye environment- increased ph and amino acids Demodex Blepharitis secondary to demodex consuming epithelial cells Micro-abrasions causes reactive hyperkeratinization which leads to cylindrical dandruff Lacey N et al. Demodex Mites Commensals, Parasites or Liu J et al. Pathogenic role of Demodex mites in Mutualistic Organisms? Dermatology 2011;222: blepharitis Curr Opin Allergy Clin Immunol. 107 Oct 2010; 10(5): Demodex Demodex 50% TTO in-office weekly, 10% TTO wipes bid OU 5% TTO ointment massage Commercially available: Cliradex- 25% TTO wipe OcuSoft Demodex kit (for in-office) Ocular Surface Discomfort and Demodex: Effect of Tea Tree Oil Eyelid Scrub in Demodex Blepharitis J Korean Med Sci. Dec (12), Gao YY et al. of Ocular Itching Associated With Ocular Demodicosis by 5% Tea Tree Oil Ointment. Cornea. 108 Jan 2012: 31(1),

19 OcuSoft Tea Tree Kit Contains Tea Tree Oil + Buckthorn seed oil Ung QHS OcuSoft Cleansers