Ocular Disease - Midterm II

Option 1 - refers to S. pneumoniae causing acute bacterial conjunctivitis (pg. 13)
Option 3 and 4 - refers to acute bacterial conjunctivitis

If I see sub-conj hemes with red eye, most common is strep pneumonia, but it could also be Haemophilus. So I got possibility of strep or Haemophilus. If there are no sub-conj hemes, most likely staph, especially if it’s an adult who denies an upper respiratory problem

Conjunctivitis, also known as pink eye, is an inflammation of the conjunctiva, the thin clear tissue that covers the white part of the eye and lines the inside of the eyelid. Patching the affected eye can create a warm and moist environment, which can promote the growth of bacteria and worsen the infection. Additionally, patching can lead to the accumulation of discharge, increasing the risk of spreading the infection to the other eye or to other people. Therefore, it is recommended not to patch a conjunctivitis as it can threaten the cornea, the clear front surface of the eye.

For the most part, when in doubt treat the symptoms. If the pt says, "My eyes are red and irritable." Then prescribe something to get rid of the "red" and "irritable"...NOT artificial tears. Hit it with a steroid and an antibiotic (Tobradex). Steroid reduces symptomology. Follow-up 3-5 days. If you missed something, then you'll usually pick it up at that time.

Fluoroquinolones, such as ciprofloxacin, vigamox, or moxifloxacin, are considered the best medications against gram-negative infections. These medications can be used every 2-4 hours to protect the cornea. Therefore, the statement "Fluoroquinolones are the best medications against gram negative infections" is true.

From group notes

Pseudomembranes are typically a classic sign in EKC (Epidemic Keratoconjunctivitis). This means that they are commonly seen in cases of EKC. On the other hand, pseudomembranes do not occur in primary herpes simplex and are infrequent in herpes zoster. Additionally, pseudomembranes can cause a decrease in vision. Therefore, the statement is true.

The statement suggests that the presence of follicles can indicate whether a condition is caused by a virus or toxicity. This implies that follicles may exhibit distinct characteristics or patterns in these two scenarios, allowing for differentiation between viral and toxic causes. Therefore, the answer "True" suggests that follicles can provide information about the nature of a condition.

Option 5 could be Chlamydia as well but according to Dr. S your FIRST DDx is always gonorrhea
After 2-3 weeks up to about ten weeks that’s when the virus comes in and so that’s when Herpes Simplex takes it’s time gets self established into the sensory ganglia and that’s when Herpes Simplex come up

Let’s say the kid is 5.1 days old…you go “crap 5.1 it doesn’t fall into my timeline”, you would know immediately, you would say to the physician you probably if you haven’t already, test the kid for gonorrhea and Chlamydia and let me know because we’ll treat the eye based on what’s going on and I’ll initiate a topical antibiotic to see what’s going until the lab test back. But you’ll know it’s gonorrhea or you’ll know it’s Chlamydia and that’s how you have to think.

When administering or prescribing a steroid, it is important to monitor intraocular pressure (IOP) before and during treatment. Steroids can increase IOP, which can lead to glaucoma or exacerbate existing glaucoma. By regularly monitoring IOP, any potential increase can be detected early and appropriate measures can be taken to prevent complications.

The SEIs will respond immediately to the steroid which means they will start to dissipate, but if you take the steroid off too fast, the SEIs will come back. So you have to keep the patient on a low dose SEI treatment if the SEIs are central. IF they are central that is what you want to do. The SEIs can be as deep as the anterior stroma, but usually it is around day 16 that you start to see them.

Dr. S mentioned that Azithromycin 1 gram PO was used for the associated chlamydia infection in patients with gonorrhea in the eye. This suggests that azithromycin is an effective treatment for chlamydia.

The correct answer suggests that the treatment for the presented symptoms is to provide systemic relief analgesics for pain relief and oral penicillin for the possibility of streptococcal tonsillitis. This is because the symptoms described, such as sore throat, white patches on the back of the throat, and enlarged lymph nodes, are commonly associated with streptococcal tonsillitis. However, it is important to note that Epstein-Barr virus (EBV) cannot be eliminated, so the treatment focuses on managing the symptoms caused by the virus rather than curing it.

Rule of 8's
 First rule was that it is type 8, then in 8 days you start to get what is SPK, and then the second 8 days (16 days later), you develop SEIs. The key thing to remember is that when SEIs develop, it is usually when they are non-contagious. So sometime between the day they got it and day 16, they become contagious. And this is when you saw them, and this is when you have to be suspicious. Classical, or definitive type of 8 days. Less than 5% of the population has neutralizing antibodies, which means basically you don’t usually have any immunity, which means you can contract it again right after you get it

In conjunctivitis, the inflammation of the conjunctiva, photophobia (sensitivity to light) is not commonly experienced unless the conjunctivitis has also caused significant damage to the cornea (keratoconjunctivitis). This suggests that the statement is true.

Tobramycin is the most favored drug across the nation because it is less toxic to the cornea compared to gentamicin. This allows doctors to prescribe it for a longer duration without causing toxicity in patients. Therefore, the statement is true.

Uveitis - You can also go blind, because the patient can have scarring and can get secondary inflammatory glaucoma, cataract formation – don’t want to miss a uveitis!!!!!!

Patients with EKC (Epidemic Keratoconjunctivitis) commonly experience symptoms such as photophobia (sensitivity to light), excessive tearing, and the presence of SPK (Superficial Punctate Keratitis). However, it is noted that there are minimal systemic symptoms associated with EKC. This means that patients may not experience significant symptoms outside of the eye, such as a mild fever. Additionally, the presence of SPK can cause a slight decrease in vision, with SEI (Spherical Equivalent Index) potentially dropping it below 20/40. In severe cases of keratitis, vision can drop to 20/200. Therefore, the statement that there will be minimal systemic symptoms in patients with EKC is true.

Consider any conjunctivitis to be EKC until proven otherwise, but you also have to consider HSV because where this becomes question is when you have a younger patient coming in and you think they have herpes simplex because they have SPK and sometimes the SPK can look like a dendrite. But when you stain with Rose Bengal it won’t stain on a EKC but will stain on an HSV. So Bengal is your helpful delinating factor. So you rule out dendrites, you write negative dendrites noted on the cornea.

Group notes 4-6 9am

The patient's symptoms of follicular conjunctivitis, sore throat, positive preauricular nodes, and low-grade fever are consistent with a diagnosis of PCF (Pharyngoconjunctival fever). PCF is typically caused by adenovirus, which can be transmitted through close contact or contaminated water sources such as swimming pools. This explanation is supported by the patient's history of spending hours at the local pool and the probable exposure to adenovirus in the pool water. EKC (Epidemic Keratoconjunctivitis) is another possible diagnosis, but the absence of severe eye pain and vision loss makes it less likely. Cat scratch disease and toxic conjunctivitis are not consistent with the patient's symptoms and history.

Blood and chocolate because Neisseria loves blood and chocolate but boards are going to want you to know Thayer Martin culture recommended for gonococcal along with blood and chocolate. So remember Thayer Martin because if a boards question starts with a positive Thayer Martin culture they’re pointing toward gonoccal.

Group Notes 3-23 @ 10am

Option 3 is incorrect Vernal conjunctivitis - if they did have discharge would chronically be removing disabiling thick mucus strands; often visually blurring. - pg. 25-26

Option 4 - pg. 39

Option 2 - for phylctenulosis pg. 27-28

Option 2 and 3 refer to N.Gon

The given answer correctly identifies three true statements regarding the treatment of EKC. Firstly, it states that sending the patient home with Betadine 5% sterile ophthalmic prep soln is not recommended because it can damage the corneal epithelium and cause pain. Secondly, it mentions that supportive therapy for EKC includes the use of lubricants, sunglasses, vasoconstrictors, and pain relievers like aspirin or acetaminophen for adults. Lastly, it acknowledges that the use of steroids in EKC treatment is controversial. While steroids can help reduce the membrane in cases of pseudo or true membrane, giving steroids without a specific indication does not benefit the patient as it reduces the immunological response on the eye.

Rubbing the eyes can cause mechanical breakdown of mast cells, leading to the release of histamine and exacerbation of symptoms. It can also worsen the itching sensation. Therefore, patients should be advised not to rub their eyes to prevent further irritation and discomfort.

Option 2 - describes Rubeola conjunctivitis

Option 2 - refers to EKC

pg. 46

Cool compresses, artificial tears, vasoconstrictors, those are probably the big 3 there that you put on the conj to treat the conjunctivitis.

Some doctors will prophylactically treat the patient if they feel the cornea is it risk. w/ oral antivirals. The topical treatment for Herpes simplex is Viroptic. Incredibly toxic to the eye. We have a new one out there called ganciclovir but it comes in a little gel called Zobrax gel.

No steroids although there will be a time when Dr Nishimoto will say that steroids are good and he is correct according to Dr.S. We use different ointments but when we treat the keratitis, we only treat it when we actually see something like dendrites. When you have a high risk of it occurring, that’s when you bring in prophylactic treatment.

This is the EXCEPTION TO THE RULE, a bacteria that has preauricular nodes, discharge that’s copious, big ballooned lids, happens very rapidly = hyperacute. Commonly due to Neisseria gonorrhoeae.

You put sulfacetamide 10% you hate that kid, OUCH. Within, 5-10 days you will have a toxic conjunctivitis that you will have to deal with.

Gentamicin, noffloxacin, ofloxacin or Polytrim QID - Dr. S said he prefers Polytrim

. If you need to treat it, it’s usually responsive to either macrolides or tetracyclines. So oral tetracyclines but if it is girls or boys under ten you might not use tetracycline, so if the kid is less than 10 you might have to default to erythromycin or another macrolide. Topical antibiotic for the eye – polysporin or erythromycin in a young kid does fairly nice.

pg. 5
Group notes - Lecture 1

not-available-via-ai

Avoid Reyes syndrome

pg. 14
Steroids mask evolution of infection - AVOID in mild to moderate cases.

Vitamin A is important for the conjunctiva because it is necessary for the production of mucin. Mucin is a component of tears that helps to lubricate and protect the surface of the eye. When there is a lack of vitamin A, the production of mucin is reduced, leading to the development of Bitot's spots, which are white, foamy patches on the conjunctiva. Therefore, the statement "Mucin must have vitamin A and when you deplete vitamin A, mucin you will cause Bitot’s spots to occur" explains the importance of vitamin A for the conjunctiva.

The correct answer is Strep. Alpha Hemolytic strep and Beta hemolytic strep. The patient's symptoms of conjunctivitis, cough, sore throat, and upper respiratory infection are consistent with a bacterial infection. Strep. Alpha Hemolytic strep and Beta hemolytic strep are common bacterial pathogens that can cause these symptoms.

I made up option 2 - in the manual it says IOPs are unaffected by conjunctivitis unless an IRITIS is present

Toxicity – most likely due to the preservative in the glaucoma medication.

Infants dont have enough lymphoidal tissue yet to produce follicles they can only produce papillae so you just see papillae in the lower lid. Maybe see some papillae in the upper lid

But you think Chlamydia because it’s between 5 days and 2-3 weeks.

If a patient with "red eye" reports photophobia, two possible conditions to consider in the differential diagnosis are iritis and keratitis. Iritis is inflammation of the iris, which can cause redness and sensitivity to light. Keratitis is inflammation of the cornea, which can also result in redness and photophobia. These two conditions are often associated with "red eye" and photophobia, making them important considerations in the differential diagnosis.

Option 4 is in reference to EKC

pg. 32-33

The given symptoms of a 2-year-old patient with inferior follicular conjunctivitis, positive preauricular nodes, vesicle eruption, and the presence of an internuclear cytoplasmic inclusion body suggest a viral infection. Among the options provided, Herpes simplex is the most likely differential diagnosis due to its characteristic vesicle eruption and the presence of inclusion bodies. Environmental conjunctivitis and epidemic keratoconjunctivitis may cause similar symptoms, but the presence of inclusion bodies points towards a viral etiology. Herpes zoster typically presents with a dermatomal distribution, which is not mentioned in the given information. Therefore, Herpes simplex is the most appropriate first differential diagnosis.

Group notes - Lecture 1

When membranes form, they tell you classically that they form from EKC, which is an adenovirus. They can also form from serious bacterial infections. But when you see a membrane, your first thought should go EKC, and your second thought should be bacterial. Now if they have pain, you should be thinking virus, but if they have breakdown of their conj and basically what would be sub conj hemes, you would be thinking bacterial.

Option 4 - pg. 5; the description is for Follicles

Option 3 - Conjunctivitis may appear after the fever and sore throat, not concurrently. Pg. 44