Differential Diagnosis of Conjunctivitis and Keratoconjunctivitis

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1 Differential Diagnosis of Conjunctivitis and Keratoconjunctivitis Dr. Victor Malinovsky 2006 Mechanical-Physical Trauma Corneal Abrasions Abrasions (interpalpebral/variable): a focal loss of epithelium with a clear base (superficial or deep) Symptoms: Variable-mild foreign body to severe pain and photophobia, decrease visual acuity, tearing, blepharospasms,, lid edema. Signs: Variable-small superficial punctate erosions to large epithelial defects, corneal defect that stains with NaFl,, occasionally an iritis, R/O perforation injury (Seidel sign) Etiology: Contact lenses, trauma, blunt trauma, foreign bodies, fingernail scratch, paper cuts, mascara brush, ultraviolet, chemical burns, trichiasis,, physiological factors (usually a delayed response). R/O high projectile objects Work-up: Evaluate abrasion based on A. geography B. depth C. edge quality D. edema Invert eyelids to make sure no FB Treatment: Antibiotic drops (polytrim( qid) ) & no patch, antibiotic ointment (polysporin)) & pressure patch, bandage lenses & antibiotic drops, plus cycloplegia,, topical NSAIDS, aspirin or ibuprofen for pain and artificial tears/ lubricants. No patch in contact lens wearer or tree branch or false fingernail abrasions 1

2 Prognosis: Healing within hours. See patient again in 24 hours. Diabetics with abrasions- slower healing Watch out for secondary infections and recurrent erosions 2

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4 Corneal Abrasion Controversy 4

5 Pressure patching (PP) vs. Bandage soft contact lenses (BL) ± NSAIDs vs. No patching ± NSAIDs My Management Small abrasions with mild discomfort 1 gt 5% homatropine in office: topical NSAIDs? Bacitracin,, erythromycin, or polysporin ophthalmic ointment qid Follow-up in 24 hours Moderate to severe abrasions with severe discomfort 2 gtt 5% homatropine in office 2 gtt Voltaren or Acular or dispense qid X 2 days if not PP Antibiotic ointment + PP versus BL + antibiotic solution Note: If bilateral, try to avoid bilateral PP Oral medication: OTC Acetminophen/ / Ibuprofen: Ultram or Tylenol #3 per physician Follow-up in 24 hours Don't PP or BL a contact lens related abrasion, tree branch false fingernail Use a steroid Allow > 24 hours without follow-up or Do Rule out herpes simplex Rule out infiltrates/ulceration Rule out corneal dystrophy Use lubricants after healing R/O bleeding problems, asthma R/O FBs or microperforations 5

6 Recurrent Epithelial Erosions REE (intrapalpebral( intrapalpebral) Symptoms: Usually severe pain, photophobia, and tearing- particularly early morning, upon awakening at night, or when eyelids are rubbed or opened. History: Prior attacks or previous corneal abrasion Signs: Staining (punctate( staining to large epithelial defect), focal BUT immediately, loose sheets of epith., edema and microcysts,, healing erosions may resemble a dendrite, exam other eye to R/O corneal dystrophy A. Microform- dots or small cysts, small epithelial defect B. Macroform Larger epithelial defects Etiology: Basement membrane damage from a previous injury (i.e. fingernail, paper cut, tree branch), corneal dystrophies, herpes simplex, herpes zoster, idiopathic). Course: Recurrences common-frequent (daily to infrequent monthly); the basement membrane requires 6 to 8 weeks or more to regenerate properly Diabetics may have more problems Treatment: Initially treat as an acute abrasion- patching, antibiotics, topical NSAIDs,, EW bandage lens, remove loose tissue. After epithelial defect heals, then 5% sodium chloride (Muro( 128 ointment), 2% hypertonic solution, lubricants, Refresh plus,gels, Celluvisc tears, bandage soft contact lens, anterior stromal needle puncture, excimer laser therapy, superficial epithelial keratectomy, systemic tetracycline ( 250 mg bid x 12 wks) Debridement Indicated in severe cases with extensive loose epithelium Zone of defective adhesion is determined by anaesthetizing the cornea and then touching the involved area with sterile moistened cotton tip and the abnormal tissue will become loose and turn grey Place proparacaine anesthetic in eye to determine extent of abnormal epithelium (grey color) With cellulose sponge remove loose epithelium 6

7 Failure to heal-management Anesthetize eye, remove loose tissue, apply bandage lens if continued RE then If < 30% of cornea and outside visual axis, then apply micropuncture therapy (25 gauge bent needle) plus bandage lens If > 30%, then superficial keratectomy with diamond burr polishing or PTK 7