Term
| What is SLK? And what is it associated with? |
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Definition
superior limbic keratoconjunctivitis (SLK)
An uncommon, chronic, remitting and exacerbating disorder that affects superior limbus and corneolimbus.
It is associated with contact lenses, dry eyes, and dysthyroidism. Usually middle-aged, otherwise healthy women. |
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Term
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Definition
Come in with a chief complaint of "irritated" eyes, can be bad enough they have to miss work.
Often concurrently with dry eye and THAT is what they end up being treated for. |
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Term
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Definition
10-20 year course of exacerbations and remissions.
Remissions can make the naive clinician think their dry eye diagnosis was correct. |
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Term
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Definition
Ask about dry eye, CL, and thyroid problems.
Look for classic injection pattern at the superior juxtalimbal bulbar conjunctiva. Will show staining!!** |
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Term
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Definition
No FDA approved med!
Off label use 0.5% silver nitrate. |
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Term
| What are the two types of herpes simplex? |
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Definition
Type 1: above the waist, leading ocular type
Type 2: below the waist (genital) - rarely ocular |
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Term
| What is the leading infectious cause of blindness in the United States? |
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Definition
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Term
| What do you know about HSV 1? |
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Definition
most common virus in humans.
most commonly occurs between the ages of 6 months and 5 years.
70-90% by age 25
98% of healthy people carry HSV 1. |
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Term
| Where does HSV primary infect? |
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Definition
1. eye
2. skin
3. upper respiratory tract
4. oral mucosa/lips
BUT on the next slide he says "ocular involvement is uncommon" - what?? |
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Term
| When diagnosing a primary herpes infection, what are the differentials? |
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Definition
-bacterial vs. viral
-PCF or EKC
-herpes zoster |
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Term
How do you treat a primary herpes infection?
(conjunctivitis without keratitis) |
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Definition
NO steroids.
Lubricants.
Antiviral i gt 5x/day (no corneal involvement or to prevent corneal involvement)
Acyclovir topical ung |
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Term
How do you treat a primary herpes infection?
(keratitis) |
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Definition
PEE - trifluridine (Viroptic) tid to qid
Dendrite(s) - trifluridine q2h 9gtts/day MAX |
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Term
| When should you follow up on a primary herpes infection? |
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Definition
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Term
| What is a secondary (recurrent) herpes infection? |
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Definition
| Virus becomes latent in trigeminal ganglia. You have to have a "triggering event" to reactivate it. Usually happens in CORNEA! Sometimes anterior uvea and cornea, sometimes conjunctivitis, sometimes lids, or cold sores. |
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Term
| When talking about secondary herpes infection, what are the symptoms of epithelial keratitis? |
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Definition
| Variable - from absent to severe. Eye may be painful during the first attack. In later episodes, this symptom may not be seen since recurrent herpes causes corneal hypoesthesia. |
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Term
| What is the differential between herpes simplex and zoster dendrites? |
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Definition
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Term
| What happens as the damage of a secondary herpes infection becomes more extensive? |
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Definition
Geographic or ameboid epithelial ulceration that stains with NaFl and RB.
--Usually anterior uveitis accompanies ulceration. |
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Term
| How do you treat a secondary herpes infection? |
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Definition
NO STEROIDS!
Trifluridine (Viroptic) - 1 gt q2h x 21 days
Vidarabine (Vira A) - 1/2" ribbon 5x/day
Taper antivirals!
Cycloplege/dilate for patient comfort (Homatropine) |
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Term
| What is the latest and greatest antiviral? |
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Definition
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Term
| What is the most common site of herpes infection and recurrence? |
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Definition
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Term
| How do you treat an active genital herpes lesion? |
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Definition
Oral acyclovir (400 mg 5x/day x 7 day)
(remember! 800 for zoster!)
Acyclovir ung |
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Term
| What does the herpetic eye disease study (HEDS) say? |
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Definition
| long term suppressive oral acyclovir tx reduces the rate of recurrent HSV epithelial keratitis and stromal keratitis, with the greatest benefit for patients who have experienced prior HSV stromal keratitis. |
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Term
| What is metaherpetic/trophic keratitis? |
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Definition
| Chronic ulcer secondary to epithelial dendriform keratitis due to damage to the basement membrane or underlying stromal inflammation or antiviral drug toxicity. |
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Term
| What does metaherpetic/trophic keratitis look like? |
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Definition
Round, amoeboid or geographic, edges are raised and rounded.
Stains with rose bengal. |
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Term
| How do you treat a metaherpetic ulcer? |
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Definition
Tough to treat they are indolent and just sit there. Patients nerve will be damaged, they won't feel a thing.
Withdraw potentially toxic agents, and recommend referral to corneal specialist. |
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Term
| What are 2 key characteristics of metaherpatic/trophic keratitis? |
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Definition
1. reduced corneal sensitivity
2. progressive corneal thinning can occur |
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Term
| What can happen to patients who have experienced a number of previous attacks of recurrent epithelial herpes OR had epithelial herpes treated with steroids? |
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Definition
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Term
| In terms of stromal keratitis, if no epi or endo involvement, then called ____ keratitis. |
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Definition
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Term
| Is stromal disease serious? |
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Definition
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Term
| How do you treat stromal keratitis? |
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Definition
If intact epithelium, steroids are okay!
Use antiviral concurrently with steroid.
If ulcerated epithelium, JUDICIOUS use of steroids!
+ Antiviral "load" |
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Term
| What is disciform keratitis? |
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Definition
Area of stromal edema with associated uveitis that can arise without epithelial defect being present.
-central zone of epi edema over area of stromal thickening
-folds in Descemet's membrane
-may be Type IV hypersensitivity |
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Term
| How do you treat disciform keratitis? |
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Definition
Topical antiviral
Topical steroid
Cycloplegic
Referral to a corneal specialist is recommended. |
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Term
| What does varicella/zoster virus infect? |
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Definition
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Term
| Who does a primary varicella infection infect? |
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Definition
Usually children, and is transmitted via skin papules and pustules.
Incubation time is days to years. |
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Term
| What are the symptoms of varicella and how do you treat it? |
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Definition
Skin lesions (ocular complications are rare).
Treat:
Analgesic
Antipyretic
Antipruritis
General hygiene |
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Term
| Virus reactivation (shingles) in __% of patients who had chickenpox. |
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Definition
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Term
| Herpes zoster (acute phase) infects tissues innervated by _______. |
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Definition
| the ophthalmic division of the trigeminal nerve (unilateral) |
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Term
| What is Hutchinson's sign? |
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Definition
| breakout on the tip of the nose! |
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Term
| What are the systemic sxs and ocular sxs of herpes zoster? |
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Definition
systemic: pain, fever, malaise, nausea, headache
ocular: 50-75% of patients with HZO develop ocular lesions
(sometimes you will have ocular involvement WITHOUT hutchinsons sign) |
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Term
| How does herpes zoster present? |
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Definition
Can mimic or cause almost any ocular disease!
-rash
-preauricular lymphadenopathy
-vesicle formation over the forehead, periocular skin and nose
ocular:
lids are primarily affected (trichiasis, entropion, ectropion, madarosis, poliosis)
conj +/- conjunctivitis, pseudomembranes, punctal stenosis, vesicles on lid margin |
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Term
T/F
Herpes zoster have end bulbs. |
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Definition
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Term
Herpes zoster acute phase:
Optic presentation? |
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Definition
Episcleritis.
Diffuse or nodular scleritis.
Iritis (50%) with KPs and posterior synechiae, glaucoma, iris atrophy.
PSC from steroid use or chronic uveitis.
Vasculitis, perivasculitis, CRVO, CRAO, acute retinal necrosis.
Optic neuritis.
Palsies. |
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Term
| How do you treat herpes zoster (acute phase)? |
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Definition
Oral acyclovir (800 mg 5x/day for 7-10 days)
OR
Oral famciclovir (500 mg tid x 7 days)
OR
Oral valacyclovir (500 mg tabs QD x 7 days)
& treat pain |
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Term
Herpes zoster (chronic phase)
List 9 ocular findings. |
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Definition
1. conjunctivitis (mucus)
2. scleritis
3. nummular keratitis
4. disciform keratitis
5. exposure keratitis
6. mucous plaque formation
7. iris atrophy
8. glaucoma
9. posterior segment (viritis, retinitis, optic neuritis) |
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Term
| Herpes zoster prevention/vaccine |
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Definition
Varivax for chickenpox.
Zostavax for shingles. |
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Term
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Definition
Systemic viral disease.
40% fatality rate.
No specific treatment.
Eradicated in 1977. |
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Term
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Definition
Contact with ill animals or direct/respiratory contact with infected persons.
Ocular: BLINDNESS. |
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Term
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Definition
Virus used for smallpox vaccination. Eye involved through auto-contamination from vaccination site.
Ocular: lid pustules/ulcers, follicular conjunctivitis, keratitis |
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Term
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Definition
Acute, highly contagious.
Maculopapular rash.
Inflammation of respiratory tract.
KOPLIK SPOTS on buccal mucosa (bright WHITE spots).
Conjuntivitis. |
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Term
| How do you treat rubeola (measles)? |
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Definition
Mild antipyretics and analgesics --> NOT ASPIRIN!
Warm ocular compresses, low illumination, and vaccination! |
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Term
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Definition
Mild, febrile childhood disease.
Can be transmitted to the fetus via the placenta.
Will have spontaneous abortion or will be born with rubella syndrome.
-eye (cataracts, microphthalmos)
-ear (nerve deafness)
-heart defect
-each of these about 50% |
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Term
Rubella (German Measles)
Ocular: |
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Definition
cataract (15% of infants)
anterior uveitis or iridocyclitis
"salt & pepper" retinopathy
glaucoma |
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Term
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Definition
Acute viral disease characterized by fever, swelling and tenderness of one or more salivary glands.
Ocular: dacryoadenitis
Prevent with MMR! |
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Term
| What is the second most commonly infectious disease in the US? |
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Definition
N. Gonorrhoeae hyeracute conjunctivitis
(700,000 new cases in US each year) |
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Term
| Hyperacute bacterial conjunctivitis is primarily a disease of _____. |
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Definition
| neonates and sexually active adolescents or young adults |
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Term
| Is ocular involvement common in hyperacute bacterial conjunctivitis? |
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Definition
| Nope! But when they do have ocular involvement they can go blind. |
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Term
| What are the two most common organisms that cause hyperacute bacterial conjunctivitis? |
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Definition
N. gonorrhoeae (more common)
N. meningitidis (less common) |
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Term
| How is N. gonorrhoeae (hyperacute bacterial conjunctivitis) spread? |
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Definition
Neonate (through birth canal)
Adolescent and adults (indirect or direct spread from infected genetalia)
Children and adolescent (need to rule out child abuse) |
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Term
| Bacteria that can penetrate an intact cornea: |
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Definition
Neisseria gonorrhea
Corynebacterium diptheria
Listeria
H. Egypticus
Acanthamoeba |
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Term
| What are the symptoms of a hyperacute bacterial conjunctivitis? |
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Definition
SUDDEN, rapid onset (24-48 hrs)
DISCHARGE!!
Secere hyperemia
Chemosis
Eyelid swelling
Ocular pain
Tenderness of the globe & periorbital discomfort
Along with: blurred vision, quickly progressive, and note that discharge quickly recurs when wiped away. |
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Term
| What are the signs of hyperacute bacterial conjunctivitis? |
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Definition
Begins unilateral --> bilateral.
Ballooning of lids (build-up of trapped purulent discharge).
Severe hyperemia
Copious discharge!
Highly contagious! |
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Term
| How do you diagnose hyperacute bacterial conjunctivitis? |
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Definition
Treat aggressively!
Requires culture and sensitivity immediately.
Teat for concurren chlamydia.
STD workup for pt and partnet. |
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Term
| How do you treat hyperacute bacterial conjunctivitis? |
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Definition
Ceftriaxone 125mg IM in a single dose
PLUS
Azithromycin 1g orally in a single dose
OR
Doxycycline 100mg orally
ALWAYS check CDC website!! |
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Term
| Systemic therapy for neonatal hyperacute bacterial conjunctivitis? |
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Definition
Ceftriaxone 25-50mg/kg IV or IM
Prophylactic treatment for infants born to mothers who have untreated gonorrhea. |
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Term
| What is an alternative therapy for hyperacute bacterial conjunctivitis? |
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Definition
used to be fuoroquinolones but they are experiencing resistance so now the drug of choice is celphalsporins
-Usually treated for concurrent chlamydial infection! |
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Term
| How often should you follow up with hyperacute bacterial conjunctivitis? |
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Definition
Every day until consistent improvement!
May require hospitalization, purulence calms in 48+ w/proper treatment.
Conjunctivitis may last 1-2 weeks.
Pt and sexual partner(s) need evaluations for other STDs. |
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