Challenging Anterior Segment Cases. Benjamin P. Casella, OD, FAAO

Transcription

1 Challenging Anterior Segment Cases Benjamin P. Casella, OD, FAAO

2 Disclosures Have lectured or been a consultant for: Allergan Carl Zeiss Hydrogel Vision

3 31yoWM My eye is irritated, and I want you to fix it!!! I ve tried Tobradex, and it didn t help.

4 31yoWM Questions???

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6 31yoWM Management Referred patient back to his retinal surgeon for repair of his displaced scleral buckle Signs and symptoms disappeared thereafter

7 Eye Irritation The Requisites

8 Why Is This Eye Irritated? 4 grossly over-simplified and ridiculously generalized categories: Inflammatory Infectious Mechanical Hemorrhagic

9 Inflammation 3 points to note Every part of the anterior segment can become inflamed Inflammation can come in many flavors Inflammation can be progressive

10 Inflammation My workhorse anti-inflammatories Fluoromethalone (FML) Tobramycin/dexamethasone (Tobradex) Difluprednate (Durezol) Alcaftadine (Lastacaft) Oral Ibuprofen (Advil) Oral Prednisone

11 A Word On Steroids Suspensions = different pharmacokinetics on the ocular surface Generic prednisolone acetate = issues with penetration and with staying in suspension form This may be especially important in the presence of uveitis

12 A Word On Steroids Oral steroids are readily available generically in 5mg or 10mg tablets Cheap Math is easy with tapering Loading dose is typically 40-60mg

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15 Dry Eye Disease Dry eye disease is progressive and has inflammatory components, causes, and sequelae Dry eye disease can be owned from start to finish by Optometry

16 Dry Eye Disease My dry eye workhorses Topical cyclosporine (Restasis) 1 drop easy dosing no preservative treats all layers of the tear film no long term fears Oral Doxycycline

17 A Word On Doxycycline Widely used for MGD Typically 50mg to 100mg q.d. for a couple of months and implement omega 3 FA supplementation concurrently 20mg available It is a tetracycline Not for kids, pregnant, nursing, pt s on blood thinners

18 Infection 3 points to note Every part of the anterior segment can become infected Infections can come in many flavors Infections can be progressive

19 Infection My workhorse anti-infectives Polymixin B/trimethoprim (Polytrim) Tobramycin/dexamethasone (Tobradex) Oral Levofloxacin (Levaquin) Oral Azithromycin (Zithromax)* * when I need it Oral Amoxicillin/Clavulanate (Augmentin)

20 55yoWM My eye is irritated, and I want you to fix it!!!

21 55yoWM Questions???

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23 Antivirals Trifluridine Generic for Viroptic Readily available from several manufacturers Q2h dosing Corneal toxicity!!!

24 Antivirals Zirgan Gancyclovir ophthalmic gel Much less corneal toxicity 5x/day until ulcer heals, then t.i.d. x 1 wk

25 55yoWM However, there s some stuff that I m allergic to.

26 Antivirals What if you need an oral antiviral???

27 Herpes Simplex Virus (HSV) World s most popular virus??? Most humans infected by adolescence Type 1 and 2 Based on where they generally go dormant

28 HSV Acyclovir (Zovirax) 400mg p.o. 5x/day x 7-10 days 400mg p.o. b.i.d. for maintanence Valacyclovir (Valtrex) 1000mg p.o. b.i.d. x 7-10 days 500/1000mg p.o. q.d. for maintanence Famcyclovir (Famvir) 250mg p.o. t.i.d. x 7-10 days 250mg p.o. b.i.d. for maintanence

29 Oral Antivirals Adverse effects Nausea Rash Diarrhea Headache Contraindications Hypersensitivity Renal dysfunction (high doses) Intolerance

30 Herpetic Infections Vesicles are a sign of herpetic infection

31 Not To be Confused With HZ O Herpes zoster ophthalmicus Varicella-zoster virus Rash / vesicles / ulceration Patient contagious until lesions crust Headache / fever / malaise x 2-3 days prior Start therapy w/in 3 days of symptom onset However, treat even if outside that window Big reason to treat is to prevent post-herpetic neuralgia

32 HZO Conjunctivitis most common ocular manifestation Can also have uveitis, episcleritis, keratitis, scleritis, optic neuritis, retinitis, cranial nerve palsies Hutchinson sign increases risk of ocular manifestations (especially uveitis)

33 HZO Acyclovir 800mg p.o. 5x/day x 7-10 days Valacyclovir 1000mg p.o. t.i.d. x 7-10 days Famcyclovir 500mg p.o. t.i.d. x 7-10 days

34 Post-herpetic Neuralgia Analgesics Steroids 10-60mg p.o. (divided b.i.d., etc.) Tapered over 2-3 weeks Capsaicin ung (Zostrix) Tricyclic antidepressants Gabapentin (Neurontin) Lidocaine patch

35 Antivirals Topicals are pregnancy category C Orals are pregnancy category B!!!

36 Antivirals Herpetic Eye Disease Study Any herpetic infection can be treated orally Corneal considerations???

37 Management of 55yoWM Oral valacyclovir 1000mg b.i.d. and return in 3-5 days for follow-up Patient enjoyed complete resolution of the lesion and now goes to a cornea specialist for his eye care as per the wishes of his primary care physician

38 20yoWF My eye is irritated, and I m pregnant Oh yeah, and this has been going on for 4 months

39 20yoWF Questions???

40 And I ve been several other places and tried everything

41 Chlamydia Conjunctivitis Azithromycin Zithromax or Z pak (500mg q.d. on day one, then 250mg q.d. on days 2-5) 1 gram single dose for Chlamydia trachomatis (repeat regular dose if needed)

42 Mechanical Eye Irritation: Foreign Bodies Inverting lids will tell you a lot If metal (or any penetrating substance) is suspected, dilation is mandated Never pass up the opportunity to tell some to wear safety glasses

43 Foreign Bodies What would you do for the lesion? What would you do for the pain?

44 Hemorrhagic Irritation Subconjunctival hemorrhage History will tell you a lot Stain to check for abrasions isn t a bad idea Be wary of recurrences with no clear cause Get a look at the optic nerves

45 Terson Syndrome

46 Terson Syndrome Ocular hemorrhages (typically vitreous or conjunctiva) in association with subarachnoid hemorrhages Subarachnoid hemorrhages carry a considerable risk of mortality

47 54yoAAM My eyes are really irritated, and I m currently incarcerated for theft.

48 54yoAAM Questions???

49 54yoAAM Management Pt does take Xalatan, but has been doing so for years So FML q2h OU and rtc x 1 week 1 Week later: much better Recurrence after tapering gtt

50 54yoAAM Management Get me the newest bottle of latanoprost and the one before that Different manufacturer for the newer bottle

51 All Drops Are not Created Equal Not even different bottles of the same medication Generic latanoprost Over 10 companies make it One of those companies is Pfizer, who created Xalatan

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53 26yoAAF Both eyes have been aching lately when I move them around. Medications include: Orthotricycline Crestor Tylenol 3 (prescribed for eye pain)

54 26yoAAF Management Is it likely to have bilateral retrobulbar optic neuritis??? What about her med s?

55 26yoAAF Management Statins Commonly prescribed for hypercholesterolemia Can reduce cells ability to regulate lactic acid excretion Lactic acid build-up from anaerobic respiration is what makes you sore after working out Drinking lots of water can facilitate lactic acid excretion

56 Thank You!