William J. Faulkner, M.D.
wfaulkner@cincinnatieye.com
URGENT MATTERS
OR
URGENTS MATTER
Urgent Matters
Urgent Patients Deserve Urgent Care
Dry Eye: Diagnostic tool, 4 best “new”
treatments (last 5 years)
II. Blepharitis: An FDA approved procedure we
have
III. Conjunctivitis and other inflammation: Make a
firm diagnosis; a powerful potion
IV. Cornea Abrasion: Heal it faster
V. Cornea Ulcer: A better bug killer, a new
device
I.
Urgent Patients Deserve Urgent Care
VI. Herpes Simplex: Find a less toxic antiviral
VII. Herpes Zoster: Where’s the shingles?
VIII. Floaters: Cure with an injection?
IX. Pain in the eye: Why
X. Visual Loss: Exam is normal, what is it?
I
Dry Eye-DEWS Report
Dry Eye is a multi-factorial disease of the
tears and ocular surface that results in
symptoms of discomfort, visual
disturbance, and tear film instability with
potential damage to the ocular surface. It
is accompanied by increased osmolarity
of the tear film and inflammation of the
ocular surface.
Advances in Dry Eye, Blepharitis Knowledge
 1993
 2003
 2006
 2007
 2011
NEI workshop: Types of dry eye:
tear deficiency vs. evaporative
Delphi panel: Diagnosis & treatment
Aesclepius Panel: Importance of
steroids
Dry Eye Workshop: Clarify state of
the art, “The Bible”
Meibomian Gland Disease Workshop:
Classify and treat
Dry Eye Disease: An Immune-Mediated
Inflammatory Disorder
Inflammation disrupts
normal neuronal
control of tearing
Lacrimal Glands:
• Neurogenic inflammation
• T-cell activation
• Cytokine secretion into
tears
Interrupted Secretomotor
Nerve Impulses
Tears Inflame Ocular Surface
Cytokines
Disrupt Neural Arc
Stern et al. Cornea. 1998:17:584
Diagnostic Dilemmas in
Ocular Surface Inflammatory Disease
Key symptoms:
Allergy- itching inner
canthus
Allergy
Blepharitis
Blepharitis-burning
Conjunctivochasis-pain
on touch or down gaze
Dry Eye-Discomfort
Conjunctivochalasis
Dry Eye
Millions of People
Ocular Surface Disease is
Markedly Under-Diagnosed
60
55.55
50
40
39.0
30
20
16.55
10
0
EPCUndiagnosed Total Dry Eye
Diagnosed Dry
Dry Eye
Patient
Eye
Population
 There are an
estimated 55
million Americans
with dry eye
disease. Most of
them are elderly.
 An estimated 39
million dry eye
sufferers may not
have been
diagnosed by an
eye care
professional.
Economic Burden of Dry Eye Disease
 Medical treatment costs: $700-$1300 per
patient per year
 For USA, this would be $3.8 billion per year
 Productivity loses: $12,000 to $18,000 per
patient per year
 For USA, this would be over $55 billion per
year!
Yu J, Asche CV Fairchild CJ. The Economic Burden of Dry Eye Disease in
United States. A Decision Tree Analysis, Corn 2011;30 (4) 379-87
Dry Eye Syndrome - DEWS Classification
Make the Diagnosis
 History and OSDI
 Exam: osmolarity, tear volume, BUT,
staining, oil glands
Conjunctival Stain with Fluorescein
 Possible with wratten #12 filter
“Tear osmolarity may reasonably be
regarded as the signature feature that
characterizes the condition of ocular
surface dryness…this may become the
gold standard for diagnosis.”
CORNEA, 3rd Edition, Vol 1 Krachmer, Mannis, Holland, 2011, p 136
Hyperosmolarity
Osmolarity
 A property of a solution which depends on the
concentration of the solute per unit of total
volume of solution
 Normal isotonic tear & plasma osmolarity = 290
mOsm/L
 Abnormal (dry eye) = 308 OR difference in
readings between the eyes ≥ 8 mOsm/L
 Hyperosmolarity is part of the definition of dry
eye from 2007 DEWS study.
 Hyperosmolar tears are too salty.
Osmolarity cont.
 Best single diagnostic test for DES
(72% sensitive, 91% specific)
 Testing requires only 50nL of fluid and 10
seconds
 Number not only makes or excludes diagnosis
but also describes severity
 Dr. Jeff Gilbard was one of first to understand
this concept which resulted in the invention of
Hypotears
 Utility is obvious in anterior segment surgery,
contact lens patients, ocular surface disease
patients
Osmolarity cont…
 In DES, 30% of cases may have one reading in
the “normal” range due to compensatory
mechanism (unstable tear film from evaporative
or aqueous deficiency).
 Normal osmolarity rules out dry eye
 If possible have patients avoid artificial tears for
2 hours before testing
 Topical anesthetics and topical fluorescein
destabilizes tear film but only for about 10
minutes
 CLIA certification required but procedure is
easier. (Clinical Laboratory Improvement Act).
Osmolarity cont…
 Cost of device approximately $9,650 and
$10-$15 cost per patient for test card
 CPT Code-83861 reimburses $46.80 for two
eyes
 Signs/symptoms disparity: Dr. Lemp has large
group of patients with objective evidence of
DES…only 70% are symptomatic.
What is Your Number?




HgAlc?
Cholesterol?
Financial # ?....ING?
Osmolarity!
Beneficial to grade severity, communicate with
patients and improve compliance
Is it DED, MGD, or Mixed
 Lemp et.al. study, Cornea, May 2012
 299 subject U.S. and Europe, 224
qualified
 79 patients=35% only MGD
 23 patients=10% only aqueous deficiency
 86% of patients with DED had signs of
MGD
II
Blepharitis
Posterior Lid Margin Disease
 Clinical Findings
 Posterior Lid Margin
 Inspissation of glands
 Erythema &
telangiectasia
 Pouting of oil
 Gland drop out
 Rapid tear break up
time
International Workshop on Meibomian
Gland Dysfunction (March, 2011)
“ Meibomian gland dysfunction is a chronic,
diffuse abnormality of the meibomian glands,
commonly characterized by terminal duct
obstruction and/or qualitative/quantitative
changes in the glandular secretion. It may
result in alteration of the tear film, symptoms of
eye irritation, clinically apparent inflammation,
and ocular surface inflammatory disease.”
Posterior Blepharitis
 Meibomian inspissation
 Lid thickening, erythema, hyperkeratinization,
telangiectasia, pouting, dropout
Tear Physiology
 Normal lipid spread horizontal
(vertical in MGD patients)
 Tear film thickness
 74.5 mm in normal eyes
 43.8 in MGD eyes
 Lipid spread time
 0.36 seconds in normal
 3.54 seconds in MGD eyes
Pathophysiology of Meibomian Gland
Disease
• Lid bacteria secrete lipases which
break down lipids from soaps to fatty
acids (foam).
• Normal meibomian gland secretions
convert from unsaturated lipids
which melt at body temperature to
saturated fats which inspissate the
meibomian glands.
Blepharitis Etiology
 Quorum Sensing: All bacteria, gram – and
gram + , communicate their presence and
within and between species.
 As the bacterial population grows, it reaches
a threshold for the activation of signaling
pathways.
 Staph epidermidis produces virulence factors
leading to production of cytokines and
attraction of neutrophils.
Dry Eye/Blepharitis
Top 4 Treatment Advances Last 5 Years
 Azasite
 High quality omegas
 Lotemax ointment
 Lipiflow
Blepharitis Antibiotic Treatment
Goal is reduction or alteration of
pathogenic bacterial levels, not
eradications
Our body has 10x more bacteria than
cells (500 species)
The Ideal Antiinfective Agent
Broad spectrum
Bacteriacidal
Biocompatible
Non-cytotoxic
Immunomodulatory
Biovailable
Favorable pharmacodynamics
Anti-Inflammatory Effects of
Macrolides
 The anti-inflammatory effects of
Macrolides have been known for the last
40 years
 Macrolides prevent the formation of:




Pro-inflammatory mediators
Cytokines
Prostaglandins
TNF-α
Macrolides
Mechanism of Action
 Inhibits protein synthesis by reversibly binding to
the 50S ribosomal subunit

Suppression of RNA-dependent protein synthesis
 Macrolides typically display bateriostatic activity,
but may be bactericidal when present at high
concentrations against very susceptible organisms
 Time-dependent activity
`
Single-Dose Rabbit:
Azithromycin Concentrations in Cornea
1
Eye Drop
Cornea
Azithromycin ng/g
50,000
40,000
Azasite 1% (single drop)
Aq. Azithromycin 1% (single drop)
30,000
20,000
10,000
0
0
2
4
6
8
10 12 14 16 18 20 22 24
Time (hr)
1. Data on file. Inspire Pharmaceuticals Inc, Study report DE 041-00
48
72
Mean 96SE
120
144
Single-Dose Human: Median Conjunctival
Concentrations of AzaSite® vs Vigamox®1
2,3
2,3
1.
2.
3.
Data on file. Inspire Pharmaceuticals Inc. 2008
Data on file. Inspire Pharmaceuticals Inc, NDA Study Report 01-401-003
Data on file. Inspire Pharmaceuticals Inc, NDA Study Report 01-401-004
Patient Compliance and Dosing
Compliance
 Literature review of 76
studies show
Dosing
(Times/day)
1. Claxton et al. Clinical Therapeutics. 2001; 23:1296-1310.
 Compliance increases
with decreased dosage
regimen and
complexity1
 79% compliance with
QD regimen vs 51% for
QID regimens
(p=0.001)1
 Simpler, less-frequent
dosing results in better
compliance in a variety
of therapeutic classes1
Conclusions
AzaSite® (Azithromycin) 1.0%
Broad spectrum, even covers “resistant”
organisms, 88% G+, 92% GConcentrated in tissue with long half life
and extensive penetration
Dosing convenient due to Durasite vehicle
Excellent efficacy for conjunctivitis,
blepharitis off label
Essential Fatty Acids
 Omega3/omega 6
 Ideal ratio 1:1-1:4
 Common ratio 1:15
 Sources
 Omega 6: Animal fats, Vegetable oils, processed
foods
 Omega 3: Fish, avocados, mangos, flaxseed oil
Nutritional Supplements for Dry Eye
ARVO Presentation, May 4, 2003, Trivedi, Sana,
Gilbard, et.al.
 Harvard Women’s Health Study involved 39,876
patients
 2-4 servings/wk of tuna fish reduced the risk by 18%,
compared to <2 servings/wk
 5-6 servings/wk of tuna fish reduced the risk by 66%,
compared to <2 servings/wk
 The greater the Omega-3 intake the lower the risk for
dry eye
OMEGA 3 EFA’S
Omega 3 EFA’s
 Omega 3 deficiency, 96,000 death/yr in US…6th
leading cause of death 2009 publication
 In Japan DES & ARMD nearly nonexistent
 EPA & DHA from Pelagic fish by far most effective
source
 ALA & Flaxseed much cheaper, not nearly as
effective, convert to pro-inflammatory compounds
 RBC saturation index measurable by simple finger
stick blood test
Omega 3 EFA’s
 RBC saturation index: Level of 0-4 deficient,
level of 8% or greater is cardio protective,
reduce the risk of sudden death by MI by 90%
(Siscovek, JAMA 1995)
 Recommend at least 2 grams of EPA & DHA
daily to achieve therapeutic level; 10 minutes
before meal minimizes SE
 No interaction of triglyceride form with
anticoagulants
Dry Eye Omega Benefits
 Clinical study: Greg Smith, MD
 20 patients DES, Rx 2400 mg qd x 8 weeks
 Blood levels EPA, DHA, omega 3 index all
significantly ↑ , arachadonic acid ↓
 100% better on OSDI scores
 70% completely asymptomatic
 Documented ↑ B.U.T., ↓ cornea staining,
improvement in osmolarity
Dry Eye Omega Benefits
 DEOB contain natural triglyceride, requires extra
processing but increases absorption nearly twofold &
eliminates fishy aftertaste.
 DEOB uses molecular distillation to ensure removal of
all Hg and carcinogens
 Only comparable brands to my knowledge: Nordic
Natural & Icelandic, both more expensive
 Lovaza, the only prescription omega 3 is ester, not
triglyceride, with poorer absorption
Inflammation: Role of Steroids
Progenitor Cell Proliferation
Topical Steroids
Work Here
Mast Cell
Degranulation
T Cell
Topical Steroids
Work Here
Phospholipase A2
Arachidonic Acid
Tryptase
Chymase
Histamine
Heparin
PAF
Lipoxygenase
Cyclo-Oxygenase
Hydroperoxides
Cyclic Endoperoxides
Leukotrienes
(LTB4, LTC4, LTD4, LTE4)
Prostacyclin
(PCI2)
Thromboxane A2
(TXA2)
Prostaglandins
(PGD2, PGE2, PGF2)
PAF = platelet-activating factor.
Adapted with permission from Donnenfeld ED. Refract Eyecare. 2005;9(suppl):12-16.
Role of Steroids
 Anti-inflammatory so may help dry eye
 Possible role: Start Lotoprednol (Alrex or
Lotemax) with Restasis
 Taper steroid as symptoms decrease
 Side effects of long term use: cataracts,
glaucoma, infection, preservative
problems
Lotemax Ointment
 First new monotherapy steroid ointment in US in over
20 years
 First preservative free steroid ointment in US
 On label for post op inflammation s/p cataract surgery
 Bonus benefit for patient with dry eye
 Option is off label use with bleph/DES patient…a 1-2
punch with Azasite
 Also reuse medication in patient on Azasite still
symptomatic
 SE profile much more benign than other
steroids…potency good
 Another possible indication: HSV immune stromal
keratitis
Lipiflow
 ~75% of OSD involved a mixed diagnosis:
aqueous deficiency + MGD
 The incidence of MGD ↑ about 10% each
decade… incidence in a 60 yo is about 60%
 Meibomian Gland Evaluator:
≤ 4 secreting glands: 95% probability of
symptoms…8-10 or more secreting glands:
5-10% probability of symptoms
Lipiflow cont…
 Heat (43 C or 109 F) softens MG blockage and
pressure (up to 6 psi) evacuates glands without
pain
 Treatment time = 12 minutes/eye
 Cost $85,000 - $99,000, “volume related
options available”.
 FDA approved: July 11, 2011
 Many describe the treatment as comfortable
and soothing, even like an “eye spa”.
Lipiflow cont…
 Statistically significant superiority in trials
vs. traditional treatment (heat, wash,
omega’s).
 Why it works…theories 1. “Reset the clock” to allow MG function
and normal lipid production
 2. Evacuating stagnant lipids reduces
inflammatory mediators and allows healing
Lipiflow cont…
 Benefits are immediate in some, in 2-4
weeks in others
 Korb: “a game changer,”
Holland: “a significant breakthrough”.
 Second generation device now FDA
approved allows bilateral simultaneous
treatment
Who to Treat
 Happiest patients are mild-moderate
disease who become asymtomatic
 All patients start out at stage 1
 More difficult and less satisfying to treat
advanced disease
Cyclosporine A Treatment
of Blepharitis
 Topical Cyclosporine A in the treatment
of meibomian gland dysfunction
 Cyclosporine 0.05% bid
 Significant improvement in meibomian gland
inclusions, tarsal telangiectasia, and corneal
staining
Perry, H., Doshi, S., Donnenfeld, E., et al. Topical Cycosporine in the
Treatment of Posterior Blepharitis, Cornia, 2006
Boston Scleral Lens
 PROSE=Prosthetic Replacement of the
Ocular Surface Ecosystem
 Invented by Dr. Perry Rosenthal, Boston
 Fluid ventilated gas permeable contact lens
rests entirely on sclera (15mm diameter)
 Mask severe astigmatism or manage severe
ocular surface disease
 Custom fitting process averages 3.5
lenses/eye over two weeks or longer
 Computerized fitting linked to digital lathe
dowel by Bausch & Lomb, recently ~
90% successfully fit
 Cost in Boston $7600
Cost in Cincinnati $925
III
Viral Conjunctivitis
 Much more common than bacterial
 Usually adenovirus
 •Pharyngeo-conjunctival fever
 •Epidemic keratoconjunctivitis
 AM matting, sticking, FB sensation, red
 Conjunctival follicles, lymphadenopathy
 Some cases develop keratitis:
 PEE → PEK → SEI’s
 Course highly variable: 1-2 weeks vs 4- weeks or > ?
Viral Conjunctivitis




Infectious precautions, hand washing, etc
Contagious for at least 1 week
Self limited, usually benign
Rx: cool compresses, frequent artificial tears,
consider decongestant antihistamine drops,
consider Zirgan off label
 Zirgan shown to shorten symptomatic course
from 18.5 days to 7.7 days vs. artifical tears
Viral Conjunctivitis
 If SEI’s need anti-inflammatory
 Cautious re steroids: prolongs viral
shedding and difficult to wean
 Better is Cyclosporin, documented
effectiveness
to reduce subepithelial infiltrates
Adenoplus
Adenoplus
 53 serotypes of adenovirus
 Cell culture takes 3 weeks
 Rapid immunoassay for viral Ag’s in 10
minutes
 Polymerase chain rxn, microfiltration
technology Accuracy of Dx approaches 100%
 Eliminate unnecessary Ab Tx if +
 Sensitivity 89%, specificity 96%
Atopic Kerato Conjunctivitis
 Severe allergic often all year, chronic
 Often thickened lids, hyperemia PEK, tarsal
papillae
 Atopic dermatitis in 3% of population…perhaps ½
of these have ocular involvement; + family history
 ITCHING, watery, mucous discharge, red, blurry,
pain, photophobia
 Skin scaly, “woody”…possible cicatricial ectropion,
lagophthalmos, keratitis, loss of vision
 Pathophysiology: type I & IV hypersensitivity
Atopic Treatment
 Coordinate with allergist, environmental modification
 Antihistamines, mast cell stabilizers, cyclosporin,
steroids, surgical resection of or cryo of papillae
Atopic Treatment-Tacrolimus
 Tacrolimus (Protopic) ointment, 0.1 or 0.3%
 Macrolide immunosuppressant inhibits T lymphocytes
(like CsA)
 FDA approved 1994, system use for organ transplants,
potent
 On label for atopic dermatitis on skin
 Off label used in conjunctival fornix BID
 Reported case of resolution of symptoms in 2 months
after failure on all of above; tapered uneventfully over 4
months…no side effects
Superior Limbic Keratoconjunctivitis
 Red eye superiorly, FB sensation, pain
 Thickened superior conj, staining of upper
cornea & conjunctiva
 Etiology unknown
 50% have thyroid disease
 Rx: Try artificial tears, Restasis, punctal
occlusion
 Severe case: Silver nitrate 0.5% application
OR bandage contact lens OR conjunctival
cautery OR resection
Stem Cell Deficiency
 Edward J. Holland, MD, world expert in stem cell
transplants
 Causes: Chemical injury, aniridia, Stevens-Johnson
Syndrome, pemphigoid, CONTACT LENSES!
 Iatrogenic (multiple surgeries and medications)
 Long term anoxia leads to characteristic appearance
 Swirling abnormal epitheliopathy superior cornea
initially
 If progressive, vascularization and scarring possible
 Rx STOP CONTACTS, vitamin A ointment, steroid
drops
Stem Cell Deficiency
Scleritis
 Severe eye pain, bluish discoloration, intensely red
eye, deep vessels inflamed (immobile), no blanching
with phenylephrine drops
 Types: Diffuse, Nodular, Necrotizing
 50% have systemic disease, i.e., connective tissue
disease or Wegener’s granulomatosis
 Work up: CBC, ESR, Uric acid, RPR, FTA-ABS,
rheumatoid factor, ANA, fasting glucose, angiotensinconverting enzyme, total complement assay (CH 50)
C3, C4, serum ANCA
Scleritis Treatment
 NSAIDS
 Naprosyn 440 mg BID
 Steroids: Topical vs systemic
 Durezol q hour
 Immunosuppressive therapy
 to Rheumatologist
Topical Corticosteroids
 Prednisolone Acetate: former “gold standard”
 Betamethasone (available in Japan) shown to
be at least 6x more potent than pred acetate
 Durezol shown to be at least 2x as potent as
Betamethasone in uveitis patients
Durezol
 A novel difluorinated prednisone derivative
 Potency due to
1. 1. High glucocorticoid receptor binding affinity
2. 2. Superior tissue penetration
3. 3. Increased bioavailabilty


Emulsion, not suspension, shaking unnecessary
Small droplet size (0.11 uµ) and high solubility quickly
blankets ocular surface
IV
Cornea Abrasion
Diagnosis Symptoms: Pain, photophobia, injection
 History: Trauma, ask re contact lenses
 Exam: Epithelial defect with fluorescein,
measure or diagram, look for laceration
or FB or iritis
Corneal Abrasion
Treatment Antibiotic drops or ointment
 Broad spectrum, cover pseudomonas
 Cycloplegic agent
 No patch
 Consider NSAID
 Debride loose epithelium
 Stop contact lenses
 Consider collagen shield vs. bandage contact lens
OASIS Soft Shield
Cornea Abrasion
 Collagen Corneal Shield
• Available thru Oasis Medical
• Thin, purified collagen, 14.5mm diameter
• Soft Shields, 12,24, or 72 hours
• Clinical evidence for enhanced drug delivery,
presoak in Ab
• Promotes epithelial & stromal healing, neutralizes
collagenases, reduces corneal inflammation
• Follow up with O.D., especially before resuming
contact lenses
V
Cornea Ulcer
Should it be cultured?
3-2-1 Rule
3: Farther than 3mm from visual axis
2: Less than 2mm size
1: Less than 1+ AC reaction
If yes to all…no culture…
Rx Besivance
Quinolone Antibiotics
• Most successful class of Ab’s, derived from
chloroquine
• Generations
•
•
•
•
•
1.Nalidixic Acid
2. Ciproflaxacin
3.Levofloxacin
4. Moxifoxicin & Gatifloxacin
5. Besifloxacin
• Substitution of Chloride on molecule enhances potency
• Developed for and used only as ophthalmic preparation
• Never used systemically, causes photosensitivity
Besivance™: Indication
• Indication: for the treatment of bacterial conjunctivitis caused by
susceptible isolates of the following bacteria:
•
CDC coryneform group G
•
Staphylococcus lugdunensis
•
Corynebacterium
pseudodiphtheriticum*
•
Staphylococcus aureus
•
Staphylococcus epidermidis
•
Corynebacterium striatum*
•
Streptococcus pneumoniae
•
Haemophilus influenzae
•
Streptococcus oralis
•
Moraxella lacunata*
•
Streptococcus mitis group
•
Staphylococcus hominis*
•
Streptococcus salivarius*
*Efficacy for this organism was studies in fewer than 10 infections.
Source: Besivance full prescribing information. April, 2009.
Besivance™: Description
• Sterile ophthalmic
suspension of
besifloxacin (0.6%)
• 6 mg/mL
• 5 mL in 7.5 mL bottle
• Formulated with
mucoadhesive
technology
(DuraSite®*)
*DuraSite is a trademark of InSite Vision Incorporated.
Source: Besivance full prescribing information. April, 2009.
DuraSite® Technology
• Proprietary
mucoadhesive
delivery system1
• Polymer composed
of polycarbophil,
edetate disodium
dihydrate, sodium
chloride2
1. DuraSite is a trademark of InSite Vision Incorporated, Alameda, CA.
2. Besivance full prescribing information. April, 2009.
Incidence of Besifloxacin
Resistance Development
Clinical efficacy studies
 No quinolone-resistant strains emerged after
besifloxacin treatments of 656 conjunctivitis isolates
Nonclinical studies
 Lower frequencies of resistant variants observed in
studies of representative ocular pathogensa
S. aureus
S. pneumoniae
a
Ciprofloxacin
6.4 10–8
1.6
Frequency of mutants determined at 4
10–8
the MIC.
Cambau E, et al. J Antimicrob Chemother. 2009;63:443-450.
Moxifloxacin
—
1.6
10–9
Besifloxacin
< 3.3 10–10
<7
10–10
Besivance™: Dosage
Source: Besivance full prescribing information. April, 2009.
PROKERA
PROKERA
 Class II medical device, self retaining biological
bandage
 Sutureless cryo-preserved amniotic membrane
 Tx for OSD: ↓ pain, suppresses inflammation,
promotes epithelial healing, ↓ haze
 Is easily inserted in office, ER, or OR
 16mm with peripheral plastic rim conforms to
ocular surface
PROKERA
Indications
To maintain space between globe & lids, preventing
closure & adhesion OR promote healing in OSD…
•
•
•
•
•
•
•
•
•
Band keratopathy
Bullous keratopathy
Chemical burns
Epithelial defect
Cornea ulcer
Hi risk transplants
Superficial keratectomy
Pterygium
Stevens-Johnson Syndrome
PROKERA
PROKERA
• My experience…1st two ulcer patients with
persistent epithelial defects…one 70% healed,
one 100% healed with 3-4 days (multiple other
treatments had been tried)
• Slow release of antibiotic in which PROKERA
has been prepared reduces dose frequency
from every hour to 4x/day
• After placement close lid with tape
tarsorrhaphy
Cornea Ulcer
• Breaking New Treatment: Collagen X
Linking…Riboflavin + UV light can sterilize
cornea, kill bacteria, fungi, viruses or
amoeba…is toxic to organism’s DNA.
VI
•
•
•
•
Herpes Simplex Virus
25% seropositive age 4, 90% age 16
Leading cause of infectious cornea blindness
400,000 Americans per year
1% develop ocular manifestations during
lifetime
• Initial infection often subclinical
• After 1st infection, 50% recurrence rate
• Triggers: Stress, illness, fever, trauma, ? UV
light
HSV Classification
• I. Infectious Epithelial
Macropunctate or cystic lesions become dendritic
or geographic
• II Neurotrophic
Sterile epithelial defect over previous dendrite
• III Stromal
Immune stromal-common
Necrotizing interstitial keratitis-rare
• IV Endotheliitis
Disiciform, linear, diffuse
• V Iridocyclitis
KP’s iris atrophy, IOP ↑ or ↓
Zirgan





New treatment of choice for acute HSV
Inhibits viral DNA replication
Unlike Viroptic, is not toxic to epithelium
Approved 2010 by FDA, Sirion → B&L
Shortens duration and severity of new
infection
 Topical Gancilovir gel 5x/day 1 week,
3x/day until healed
HSV Poor Outcomes
•
•
•
•
•
•
•
Patient lacks access to care
Patient delays seeking care
Misdiagnosis
Failure to use available treatments
Failure to recognize and treat stage II
Steroids underutilized or tapered too quickly
Easier to treat a steroid induced cataract vs
penetrating keratoplasty
VII
Varicella-Zoster Virus (VZV)
• 1˚ infection: Chicken Pox, 2˚: Shingles
• Varicella vaccination available since 1995 has reduced
incidence by 80%
• Greek work herpein: to spread or creep; zoster: girdle
or zone
• Lifetime risk=10-30%, ↑ with age (50% by 85)
• Increased risk: altered immunity, neoplastic disease,
immunosuppressant, organ transplant patients,
coexisting infections, emotional or physical trauma
• After primary infection, VZV virus is latent in sensory
spinal or cerebral ganglia
Varicella-Zoster Virus (VZV)
• Ophthalmic findings: edema, itching or pain,
then maculopapular rash, then vesicular
eruption. V1 distribution (skin, lids)…possible
conjunctivitis, keratitis (punctate or
pseudodendritic) may become neurotrophic or
disciform
• Skin vesicle for 4 days, then become pustular,
may ooze or bleed, scarring or pigmentation
may result over 2-3 weeks
• Hutchinson’s sign…tip of nose involvement
increases risk of ocular complication to over
60%
Other Risks
• Trichiasis, entropion, ectropion, madarosis
• “pseudodendrites”: more superficial, have blunt
ends, lack central ulcer, minimal stain
• Scleritis possible due to vasculitis, 40%
progress to uveitis, possible secondary
glaucoma
• Neuralgia: “lancenating pain”, 20% persist
months to years…postherpetic neuralgia
• Leading pain cause of suicide > 70 year old
Varicella-Zoster Virus (VZV)
• Reactivation occurs with viral replication &
axonal transport to a unilateral dermatome
• 50% of cases involve thoracic or lumbar areas,
17% involve cranial nerves
Treatment VZV
• Supportive: Hydration, antipyretics, cool baths, hygiene
• Oral Acyclovir within 1st 72 hours, shortens duration,
reduces new lesions, speeds healing
• Adults Acylovir 800mg 5x/day 7 days
OR Famciclovir 250mg 3x/day 7 days
OR Valacylovir 1,000mg 3x/day 7 days
• Famvir & Valtrex produce higher serum levels, more
expensive…all 3 equal in days to heal & reduced pain
• Only Rx caution is renal failure
• Add corticosteroids? Moderately accelerates healing
and pain reduction, no effect on post herpetic neuralgia
Post Hepetic Neuralgia
• PHN: May coordinate treatment with pain
specialist…stellate ganglion block, cimetidine,
topical lidocaine or capsaicin, tricyclic
antidepressants, anticonvulsants, morphine
• 2006…Zostavax, more potent adult vaccine
introduced
• Recommended for > 60 year old
• Reduces VZV by 55% & PHN 66%
VIII
Floaters Update
• Posterior Vitreous Detachment: 2 requirements
• Over time gel vitreous liquefies, destabilized,
collapses from back of eye
• Vitreo-retinal adhesions weaken
• Normal from age 40-60 years
• > 65 years old, present in 2/3 of people
Anomalous PVD
 Gel vitreous liquefies but vitreoretinal adhesions
remain
 Symptoms variable, patient dependant
 Vitreomacular adhesion (VMA) may require surgical
intervention
 Injectable Ocriplasmin (Jetrea) recently FDA approved,
cost $4,000
 70% effective in separating VMA adhesion
 Dr. Daniel Miller was FDA study investigator
 Other option: Vitrectomy
Floaters Cure?
“Jetrea is only indicated for the treatment of
vitreomacular traction or vent associated with macular
hole. It will be used in just a fraction of these patients
since many do very well with surgery. I plan on using it
in poor surgical candidates or patients with very good
vision who would like to avoid surgery.”
Daniel Miller, MD, PhD
IX
Eye Pain
• Severe or chronic
• History is key: PQRST
Precipitating factors
Quality
Radiation
Severity
Timing (Frequency, duration)
• Is it anterior, posterior, intraocular or orbital
4 Major culprits:
1.Migraine…
History…ask about light sensitivity, disabling
headache, nausea & vomiting…but latter may be
absent, scintillating scotomata
2. Cluster Headache
Usually male, young to middle aged, lasts 15
minutes to 2 hours often associated with Horner’s
syndrome, rhinorrhea and lacrimation
3. Hemicrania
Pain on one side of head, may be episodic,
unremitting
More common in women
Rx Indomethacin…very effective
4.Trigeminal Neuralgia
• Extreme sporadic burning or shock like pain…
minute to constant
• Triggers: Vibration ,contact, combing hair,
touching temple, cold air
• May be idiopathic, post zoster
• Rx anticonvulsants, ? Resect frontal branch of
VN, or trigeminal decompression• Coordinate care with PCP or pain clinic
X
Loss of Vision…
“Normal Exam”…The Dirty Dozen
1. Refractive problem
Check pinhole, retinoscopy, CL over refraction
topography may reveal early keratoconus
2. Older Patient…transient loss…minutes
Amaurosis Fugax…Embolic due to carotid plaque or
cardiac arrhythmia…order CBC, sed rate…call PCP to
arrange workup
3. Older Patient…fatigue, malaise, jaw claudication:
Giant Cell Arteritis
STAT sed rate…If + temporal artery biopsy…if + high
dose system steroids
Loss of Vision…
“Normal Exam”…The Dirty Dozen
4. Reading problems
Present in 90% of Alzheimer’s patients!
5. Check visual fields

•Confrontation fields may show Homonomous
Hemianopsia…
due to CNS lesion, usually stroke…to Neurology
• Humphrey Field 24-2 Fast Pack may reveal early
glaucoma or other defects (ask re family history), HVF
10-2 more precise detector of occipital stroke
• Zebras are not extinct: tumor, carotid dissection,
metastasis
Loss of Vision…
“Normal Exam”…The Dirty Dozen
6. Check pupils
Recheck for APD…possible difficult, subtle in older
patients…dark adapt…also red top brightness, color
plates…abnormal may mean retrobulbar
neuritis…?MS, PION
7. Fluctuating vision
Dry Eye or NOMGD-Non obvious Meibomian Gland
Disease…express oil glands…irregular keratoscopy
mires…treat OSD
Obese patient buries head into pillow…Floppy Lid
Syndrome..recommend eye shield, sleep apnea
workup, to plastics
Loss of Vision…
“Normal Exam”…The Dirty Dozen
8. Lens Related Problems
• Oil droplet cataract…possibly young myope, defect
with ophthalmoscope or 90D lens or Hruby lens
• Negative or Positive Dysphotopsias…light
aberrations related to IOL…may improve
spontaneously…reassure or back to surgeon
• PCO…may be subtle, especially with multifocal
Loss of Vision…
“Normal Exam”…The Dirty Dozen
9. Heavy Vitreous Floaters
Variable vision on blinking, PVD…especially in high
myopes
10. Central Vision Complaints
Amsler grid reveals metamorphopsia…retina pathology
proven by OCT or ERG
11. Malingering/Psychiatric
Diagnose with 4 ∆ base down over good eye OR fogging
with +4D lens OR OKN drum…if non-organic, reassure
patient of no serious pathology and likely improvement
12. Quien Sabe?
Request higher authority
12. Quien Sabe?
Patient Care - Urgents Matter
Case 1
 Pink eye x 2 days
 Six months before electrocuted with 18,000
volts while installing line for Cincinnati Bell
 Lost 1½ fingers, back to work (office only)
Patient Care – Urgents Matter
Case 2
 Conjunctival cyst
 Vietnam pilot shot down, bullet to leg
resulted in auto amputation in 2 areas →
tourniquet →lived
 “Everyday is a wonderful blessing”
Thank you for your attention
William J. Faulkner, MD
Director, Urgent Care Department
Cincinnati Eye Institute
1945 CEI Drive
Cincinnati, OH 45242
513-984-5133