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4 1/11/18 Goal of Treatment in EBMD Treatment of RCE Initial conservative approach Hyperosmotics (ointment or solution) Bandage contact lenses Lubricants Treatment of RCE Severe or recurrent episodes Oral Doxy (50mg bid) w/wo a topical steroid Azasite (? MGD component) Stromal puncture w/wo Amniotic membrane other 4

5 1/11/18 Dry eye subtypes 86% of patients with a classified DED subtype demonstrated signs of Meibomian Gland Dysfunction Pure Aqueous Deficient Dry Eye (ADDE) subtype represented the smallest percentage of patients (~10%) Lemp MA, et al. Cornea. 2012;31:

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11 Y 5;G-)-;J',%0,'E)-.'G)/G")*-(/'E) =O9-9 Y 2;-%9%1/G,J%1)*/*-@,E('9'*-,/-, L)(-. Y TE)-.'G)/G,G/O'(@,L)G/-'(/G Y TE) =O9-9,=/*,(;E-;('! N$TZ9 )**0"-##>0(<80&,%=?8( Friedman, N., Kaiser, P., & Pineda, R. (2009). The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology(3rdrd ed., p. 219). N.p.: Elsevier- Health Y 2L*%(1/G,J'E%9)-)%*,%0,=%GG/+'*, ('EG/=)*+,4%>1/*Z9 Y I(/O,G'9)%*9,)*,.%*'O=%1L,9./E' Y 2;-%9%1/G,J%1)*/*- Y N$TZ9,/-,O%;*+,/+' Friedman, N., Kaiser, P., & Pineda, R. (2009). The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology(3rdrd ed., p. 220).: Elsevier- Health Sciences. 5/=;G/(,6O9-(%E.O, 3I(%'*%;9 DOE',^^7 6)00;9',./?',>"+(/OM>.)-',0G'=H9,'F-'*J)*+,-%,G)1L;9 2;-%9%1/G,N'='99)&' 2L*%(1/G,1;=%E%GO9/==./()J'9 )*,<-(%1/ j)-.,/+'x TF-'*J9,)*-%,J''E'(,9-(%1/G,G/O'(9 <-(%1/G,./?O,%==;(9 Y(%+('99)&',G%99,%0,&)9)%* Y.%-%E.%L)/,/*J,%=;G/(,J)9=%10%(- Emily, Birkholz, Nasreen Syed, and Michael Wagoner. "Epithelial-Stromal and Stromal Corneal Dystrophies:." A Clinicopathologic Review, 17 Aug Accessed 3 Nov !!

12 1/11/18 Granular Dystrophy (Groenouw Type I) #1 stromal dystrophy Autosomal dominant Snowflake granules of hyaline in VA from subepithelial scarring or dense stromal deposits. RCE s are common Granular Dystrophy-Type 2/Avellino Dystrophy Combination of Granular opacities with Lattice lines/opacities. Lattice Dystrophy (Type I) Autosomal Dominant Amyloid deposits Lattice fence appearance 12

13 1/11/18 Schnyder Corneal Dystrophy Small, needle-shaped crystals that are either white or polychromatic Epithelium remains normal Stromal and may extend into deeper Stroma Autosomal dominant Big Mac. In Mcdonalds. Retrieved from Treatment DALK (Deep Anterior Lamellar Keratoplasty) Penetrating Keratoplasty PTK Granular Surgical Treatments Penetrating Keratoplasty (PKP or PK) Deep Anterior Lamellar Keratectomy (DALK) 13

14 1/11/18 Corneal Grafts are increasing in number Registry study of total # corneal grafts per year from Number of grafts Anterior Lamellar grafts Endothelial grafts Penetrating grafts Year Coster, D. J., Lowe, M. T., Keane, M. C., & Williams, K. A. (2015, May). A Comparison of Lamellar and Penetrating Keratoplasty Outcomes. American Academy of Ophthalmology, 121(5), Penetrating Keratoplasty (PK)/(PKP) A circular button-shaped fullthickness section of cornea is removed using a trephine or a laser. A matching button is removed from the donor cornea. The new donor cornea is sewn to the host cornea with sutures. 23 years Archives of Ophthalmology 2011 Jun; 129 (6): Epub 2011 Feb 83% 14

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21 1/11/18 Symptoms: History of direct contact to cornea With contaminated fluids, contact lens, FB, minor trauma Severe eye pain Redness, irritation, FB sensation, photophobia, Reactive ptosis, enlarged pre-auricular lymph node SIGNS Pain Extreme Epi defects, erosions Limbitis Hypopyon Ring stromal infiltrate 21

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23 1/11/18 HSV Keratitis HSV Keratitis Features Unilateral presentation always suspicious for HSV Iritis with high IOP always suspicious for HSV After 2 nd episode, 70-80% had another recurrence within 10 years Bilateral involvement or prolonged HSV suggests comorbid disease (immunodeficiency or immunosuppression) Epithelial Corneal vesicles Dendritic Ulcer Geographic Ulcer Marginal Ulcer Stromal Inflitration Vascularization Haze and scarring Ulcer/no ulcer 23

24 1/11/18 Endothelitis Area of corneal edema No epi involvment pseudo-guttae and Descemet s folds th.uiowa.edu/eyef orum/cases/160- hsv.htm Neurotrophic Ulcerated Results from altered corneal innervation and decreased tear production HSV Keratitis Treatment Acyclovir (Zovirax) 400 mg 5 x daily for 7-10 days Valacyclovir (Valtrex) 500 mg 2 x daily for 7-10 days Famciclovir (Famvir) 250 mg 2 x daily for 7-10 days Trifluridine ophthalmic solution 1% (Viroptic) 1 drop 9 x a day for 7 days; can decrease to 5 x a day after 7 days if ulcer not healed. Ganciclovir ophthalmic gel 0.15% (Zirgan) 1 drop 5 x a day until ulcer heals followed by 1 drop 3 x a day for 7 days. HSV Keratitis Prophylaxis Why? 1. Multiple recurrences of HSV keratitis 2. Recurrent inflammation with scar/vascularization 3. Post-keratoplasty performed for HSV reasons 4. Postoperatively in patients with history of HSV undergoing any type of ocular surgery 5. In patients with a history of ocular HSV during immunosuppressive treatment 24

25 1/11/18 HSV Keratitis Prophylaxis Acyclovir (Zovirax) 400 mg 2 x daily for 1 year Valacyclovir (Valtrex) 500 mg 1 x daily for 1 year Famciclovir (Famvir) 250 mg 2 x daily for 1 year Treatment Principles Treat epithelial disease 1 st and stromal 2nd When using steroids use either therapeutic or prophylactic dose of orals to prevent reoccurrence In stromal cases that are controlled taper steroid gradually. Patient may never be able to get off in stromal disease and prophylactic orals may be required indefinitely. Herpes Zoster: Shingles 25

26 1/11/18 HZV Features HZV is the etiologic agent of both varicella (chickenpox) and reactivation (shingles) Can erupt anywhere on the body (15% involve the ophthalmic division of the CN 5) Clinical Manifestation Phases Pre-eruptive Phase Acute Eruptive Phase Chronic Phase (PHN) HZV Features HZV typically happens once in life (30% of adults) Recurrent episodes are atypical must consider a sinister etiology A workup for occult malignancy or other reduced cell mediated immunity concerns Post Herpetic Neuralgia Neuropathic pain syndrome that persists beyond 90 days or develops after lesions have resolved Most frequent and debilitating complication of HZV Treatment: oral anti-virals, cool compresses, analgesics, amitriptyline, gabapentin, nerve block 26

27 1/11/18 HZV Treatment Acyclovir (Zovirax) 800 mg 5 x daily for 7-10 days Valacyclovir (Valtrex) 1000 mg every 8 hours for 7-10 days Famciclovir (Famvir) 500 mg every 8 hours for 7-10 days HZV Treatment Acyclovir (Zovirax) 800 mg 5 x daily for 7-10 days? Valacyclovir (Valtrex) 1000 mg every 8 hours for 7-10 days Famciclovir (Famvir) 500 mg every 8 hours for 7-10 days Oral Corticosteroids Herpes Zoster Ophthalmicus Involves the ophthalmic division of the 5 th CN Ocular complications Conjunctivitis Uveitis Acute retinal necrosis (rare) Cranial nerve palsies Keratitis - Pseudodendrites Optic Neuropathy 27

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34 1/11/18 KCN-Acute Hydrops Symptoms: Sudden decrease in best correctd vision Foreign body sensation or pain Rupture in Descemet s Membrane self-limiting in 8-10 weeks once endo cells regenerate across the rupture /news/print/ocular-surgery-news/ %7B73f675bc-a8d4-45b1-85a fd5f91%7D/ minor-complications-can-occur-with-collagencross-linking KCN-Acute Hydrops Treatment Hyperosmotics??? Antibiotics - to prevent secondary infections Steroids - to help with inflammation PKP if significant scarring limits correctable vision. Pellucid Marginal Degeneration Bilateral corneal disorder thinning of the inferior, peripheral cornea Thinning begins about 1-2 mm above the inferior limbus and Is separated by an area of uninvolved, normal cornea between the thin zone and the limbus Manifests between the ages of

35 1/11/18 Pellucid Marginal Degeneration Pellucid Marginal Degeneration Symptoms are visual secondary to irregular astigmatism Thinning is free of vascularization or lipid infiltration which differentiates this from Terriens Butterfly wing-like pattern or kissing dives Pterygium 35

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38 1/11/18 Terrien s Marginal Degeneration Eyes are typically not injected Little pain, photophobia, or AC reaction increase in regular and irregular astigmatism are common, but usually asymptomatic to the patient. Terrien s Marginal Degeneration Treatment If asymptomatic, no treatment If patient suffers from injection or irritation steriods will resolve Refractive treatments specs Specialty CL s PKP last resort Thank You! justin.schweitzer@vancethompsonvision.com 38