Ocular Disease - Midterm II

Iritis

Keratoconjunctivitis

Conjuntivitis

Uveitis

Vernal keratoconjunctivitis

Toxcity

Contact lens wear

An STD

Chronic conjunctivitis treat condition orally to prevent re-inoculation

Chronic conjunctivitis to be treated topically and with mast cell stabilizers

Allergic conjunctivitis to be treated with mast cell stabilizers

Vernal keratoconjunctivitis to be treated topically with steroids

Allergy - Scant, ropy mucus

Hyperacute bacterial conjunctivitis - copious overflowing discharge

Vernal conjunctivitis - mucopurulent

Epidemic keratoconjunctivitis - watery discharge accompanied by a foreign body sensation

Follicles are typically associated with herpes simplex and not with herpes zoster

The patient will also exhibit a tender pre-auricular node, it may be dramatically swollen, involving the face and neck.

Vesicle formation can usually be found around the eyelids, because vesicle are classic when you have either herpes simplex or zoster. The vesicular eruptions around and on the lids are often pin-head sized, yello and fluid filled. They may be hidden b/t eyelashes. They may break and dry and forming a yello-brown crust on top.

If it has lead to a keratitis it should never be treated with steroids because it will increase the chances of HS infection

When treating the resulting keratitis, Viroptic drops must be used with caution as it is toxic to the corneal epithelium.

The three main causes of a "red eye" are a conjunctivitis, acute glaucoma and a uveitis

Acute glaucoma and uveitis are particularly troubling and should always be assessed for in a "red eye" exam because they are disease which can result in loss of vision.

Acute glaucoma is common in eastern Asian females usually over the age of 60

Age is very helpful in differentiating uveitis and conjunctivitis from one another. Since they affect different age groups and ethnicities.

Pupils are not important because in conjunctivitis there is always ipsilateral pupillary involvement.

In uveitis the pupils exhibit mydriasis and therefore are huge. The patient will not recoil when you shine a transilluminator into their eye.

Pupils size is unaffected by conjunctivitis unless iritis is also present from severe conjunctivitis and or keratitis

A patient who has acute glaucoma has a mid dilated fixed pupil and is therefore very reactive to light.

If the patient has an infectious conjunctivitis according to Dr. S you should avoid Goldmann tonometry. If you are unable to do NCT you can do digital massage

According to Dr.S when doing digital massage of the eyeballs if it feels like a Titleist tour golf ball that could point to an acute glaucoma

The anterior chamber conjunctivitises don’t cause a reaction. You're going to get cells and flare mainly with uveitis, but you can get a few cells with acute glaucoma.

Papillae are sites of lymphocyte aggregation in viral infections, chlamydial infections, toxicity, possibly in chronic allergy.

SPK distributed through out the cornea is associated with a viral infection.

Because viruses have a tendency to disperse all over the cornea a patient will often complain of a foreign body sensation.

In PCF, conjunctivitis may concurrently appear with the fever and sore throat.

If a patient administers a drop on their eye that they’re very allergic to it’s only going to be in the interpalperbral area. Therefore you must lift the upper lid during the examination.

Non-specific viral conjunctivitis is the most common form of acute infectious conjunctivitis in both kids and adults

It is responsible for 10-15% of infertility in the United States and for cervical cancer about 4%

The patient comes in with a conjunctivitis and PUS is pouring out of their eye like a bucket.

It expresses a urogenital symptomology alongside the conjunctivitis.

Males are more susceptible to Chlamydia

Haemophilus

Allergies

Herpes Simplex

Strep. Alpha Hemolytic strep and Beta hemolytic strep

Lack of Vitamin A triggers factors which activate the herpes simplex

Mucin must have vitamin A and when you deplete vitamin A, mucin you will cause Bitot’s spots to occur.

Vitamin A provides aging corneas with a protective agent against Herpes zoster

Lack of vitamin A allows for delayed hypersensitivity to occur when patients use erythromycin ophthalmic drops.

Ophthamlia neonatorum is called conjunctivitis of birth, these conditions are passed on from the mother through the birth canal

Onset of symptoms will provide a huge clue as to the condition the baby is suffering from

After 2-3 weeks up to about ten weeks you would expect Chlamydia

Onset of symptoms in the first 24-36 hours points to a diagnosis of CHEMICAL conjunctivitis either induced by silver nitrate or erythromycin within the first 24-36 hours.

If onset of signs is within of 2 days to 5 days and the baby has a swollen upper lid, there is discharge coming out of the eye and it’s within 5 days after birth, your first differential diagnosis is gonorrhea.

Conjunctivitis does not affect IOP at all.

IOPs will always be decreased when there is conjunctivitis that has manifested into a keratitis

Uveitis initially makes the IOP go down because the swelling of the ciliary body causes no production of aqueous fluid, so you have a hypotony. After time as the cells build up, the pressure goes up. The pressure only goes up to the 20s, 25, 30.

The pressures of acute glaucoma usually fall in the Mid 50s, 60s.

Gonorrhea

Chlamydia

Herpes simplex

Toxicity

Carefully evaluate the corneal epithelium for signs of perforation

Monitor IOP before treatment and during treatment

Make sure the patient does not have any pre-existing maculopathies

Make sure the pupil response is normal and EOMs are full and unrestricted.

It is the number one blinding disease in the U.S. in the young adults

The most severe serotypes of Herpes simplex are caused by 8 and 19. They cause the classics signs of the condition.

Aggravating factors that can result in herpes simplex keratitis are overexposure to UV, trauma, extreme heat, cold, uses of oral steroids, sometimes topical steroids, infectious disease, surgery.

There is no way to get a Primary Herpes conjunctivitis without some history of vesicular eruption around the lids. Pinhead-sized, yellow fluid filled, maybe hidden between the lashes, later break into dry, yellow, crusty. This is where you get the conjunctivitis.

Environmental conjunctivitis

Herpes zoster

Herpes simplex

Epidemic keratoconjunctivitis

With herpes zoster you can expect a keratitis that looks like a pseudodendrite or a mucoid plaque

Herpes zoster is characterized by a prodrome, patients get headache malaise, fever, chills like they’re coming down with a cold. The pain is preceded by this vesicular eruption, then the neuralgia.

Once the prodrome has begun to manifest, it is expected that you begin oral acyclovir within 72 hours. Untreated patients 1-1.5% will commit suicide because the post-herpetic neuralgia is so bad. If you start the patient on oral acyclovir in 72 hours, the likelihood of them commiting suicide is dramatically reduced.

You’re going to get it in your office most likely but you might not get the classic subtypes because there are 50, possibly 52 serotypes.

Glaucoma is a significant factor in zoster because patients can develop glaucoma from zoster, you have to watch out for this in older patients.

All EKC fall under the category of Adenoviruses so they going to cause an inferior follicular reaction.

They cause an lymphadenopathy and possibly have corneal ramifications.

Although highly contagious once you have had EKC you will have life long immunity from all serotypes

It is the first 8 days that the patient is most dangerous because patients are asymptomatic, and they are also contagious.

Around day 8 the patient comes back, and they have got a florid SPK. So you stain them with NaFl, and you see SPK all over that cornea.

EKC happens in the adult population in the ages between 20-40.

Treat the condition with a steroid pulse

Prescribe oral acyclovir within 72 hours

No treatment is required unless you are treating a pseudomembrane as well. The idea is you don’t want to use a topical steroid on a corneal SEI, or on a peripheral EKC because it is going to go away by itself.

Wash the eye out with Betadine (povidone - iodine) 5% sterile ophthalmic prep soln immediately

EKC

PCF

Cat scratch disease

Toxic conjunctivitis - probably from the swimming pool.

In the severe form of PCF when a kid has a lot of SPK, cant open their eyes, and also has lid edema, you can use much of the same treatment we use for EKC. Only difference is, if SEIs occur centrally and the kid’s vision goes down. It is better to wait on the topical steroid because the visual requirements for this population is not the same.

It is characterized by cough, coryza and conjunctivitis.

No topical antibiotics are going to useful for this disorder

When the SEIs appear the kid is non contagious

You will get a slew of cells in the anterior chamber and you will not have to treat it with a steroid but with a cycloplegic agent instead. Because you are going to take the stress off the ciliary body, and it is going to take the iritis away if one is present

Cat scratch disease

Herpes simplex conjunctivitis

Rubeola (red measles) conjunctivitis

Rubella (German measles) conjunctivitis

Supportive care includes lubricants, vasoconstrictors, and cool compresses. You can give acetominophen for kids under 12. Aspirin should be avoided.

As with PCF and EKC anti-virals are ineffective against Rubeola. Viroptic does not work, acyclovir doesn’t work.

The gold standard of care is Sulfacetamide 10% QID

Broad Spectrum antibiotics may not be necessary unless there is corneal involvement. If you are going to use something use Polytrim, but only if there is a risk of corneal involvement

Fungal

Herpes simplex or herpes zoster

Gonococcal

Tularemia

Syphilis

Ciprofloxacin 500 mg PO

Ofloxacin 400 mg PO

Azithromycin 1 gram PO

Streptomycin 2 grams IM

Ampicillin 3.5 grams PO

Injectable procaine G penicillin

Is characterized by sub conj hemorrhages

Is a the primary differential diagnosis when the lids have an associated eczematoid change and you flip lid and see allergic response and the pt has a hx of diaper rash, rashes on elbows, rashes on knees, skin disorders.

75% of the time is caused by Staph aureus (gram positive)

Spreads generally through fomites

Erythromycin which actually is one of the best drugs for kids. If you want to prescribe a safe medication for the cornea erythromycin is good and it kills gram positive. It comes in ointment form.

Neomycin has an allergy profile of something between 16 and 20%.

Steroids should be prescribed in all stages of acute bacterial conjunctivitis.

Polytrim is one of the better drugs against MRSA. So if we have MRSA infection in the eye, polytrim is actually a great medication because MRSA doesn’t seem to be resistant to polytrim yet.

Fluoroquinolones are just massive bacteria killers. It kills both gram positive and negative bacteria and therefore is used when you want something broad spectrum.