2014 Fall
CE@SCO
COURSE 4
Adventures of the Anterior Segment
COPE Course 42589-AS
CEE Approved
SCO HOMECOMING / FALL CE WEEKEND • OCTOBER 9-12, 2014
8/25/2014
Disclosures
Adventures in
the Anterior Segment
Walter O. Whitley, OD, MBA, FAAO
Director of Optometric Services
Virginia Eye Consultants
Walter O. Whitley, OD, MBA, FAAO has received
consulting fees, honorarium or research funding from:
– Alcon
• Santen
– Allergan
• Science Based Health
– Bausch and Lomb
• TearLab Corporation
– Biotissue
• Tearscience
– Beaver-Visitec
• Valeant Ophthalmics
– Nicox
Clinical Considerations
• Urgency vs. Emergency
• Acute vs. Chronic
Case Study
• 62 yo female presents for recent onset redness,
discharge, swelling, and irritation. OU for the last 3 days
• Current Drops:
– Restasis BID OU
– Genteal PRN OU
• Mild vs. Severe
• Ocular History
• Progressive vs. Stable
• Proparacaine to the rescue?
– Cataract Extraction with PCIOL Dec 2012 OU
– Blepharospasm treated with Botox injections
• Health - unremarkable
• Teaches 1st Grade
Examination
Assessment and Plan
• Acute Conjunctivitis
– Bacterial?? Viral?? Allergic??
• Considerations
–
–
–
–
Associated symptoms?
Are they contagious?
Impact on treatment?
Any other testing considerations?
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Acute Conjunctivitis
Viral or Bacterial??
• Common condition – affects approximately 2% of the
population annually1
• Can be caused by virus, bacteria, allergy, or other less
frequent causes
• 1-2% of all office visits2
• 20-70% of acute conjunctivitis is viral 3
• 65-90% caused by Adenovirus4
The Red Eye Protocol
Conjunctivitis Management
History  Signs  Symptoms
 Pink eye exposure, spread from one eye to the other, recent upper respiratory symptoms
 Itching, burning, foreign body sensation, tearing, discharge, eyelash matting
 Pre-auricular adenopathy, chemosis
AdenoPlus
POSITIVE
 Education: hygiene and hand washing
 Supportive care: artificial tears, cool
compresses and antihistamines
 Consider antiviral medication
 No antibiotics
THE RED EYE PROTOCOL FOR
CONJUNCTIVITIS
NEGATIVE
 Consider topical antibiotics or
antihistamines
Viral Conjunctivitis Treatment
 Supportive therapies
 Decontamination at home and hand washing
 Isolation
 Anti-viral therapy
– No FDA-approved drugs specific for the treatment
of Adenoviral conjunctivitis
– Off-label applications for some currently available
drug therapies: Povidone Iodide and Ganciclovir
NO ANTIBIOTICS REQUIRED!
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Off-Label Adenoviral Treatments
Off-Label Adenoviral Treatments
Povidone Iodide (PVI)1
 PVI (0.8%) extinguishes infectivity of free Adenovirus after 10
minutes of exposure but is less effective against intracellular
Adenovirus
Ganciclovir .15% Gel vs Preservative Free Tears (N=18)
Ganciclovir .15% gel
N=9
Preservative free tears
N=9
Recovery time
[mean (range)]
7.7 (7-12) days
18.5 (7-30) days
SEIs
2 patients
7 patients
 Isenberg et al found Povidone Iodide (1.25%) ineffective
Povidone Iodide (0.4%) – Dexamethasone (0.1%)2
 9 eyes of 6 patients with confirmed Adenovirus enrolled
 8/9 enrolled showed clinical resolution by day 4
 6/6 patients with significant reduced DNA copies by day 5
 5/6 culture positives with no infectivity by day 5
[1] Monnerat N, Bossart W, Thiel MA. Klin MonblAugenheilkd. 2006. 223(5): 349-352. [2] Pelletier JS, Stewart K, Trattler W, et al. Adv Ther, 2009. 26(8): 776-783.
Problems with Steroid Treatment
Although it may make the patient feel better…
 Risk of HSV (~3-21% of pink eye)1,2
 Increase infectivity and viral replication of
Adenovirus 3-6
 Prolongation of Adenoviral positive cultures 3-6
 Result: increase potential spread of Adenovirus 3-6
 Medical-legal issues
[1] Colin J. Ganciclovir ophthalmic gel, 0.15%: a valuable tool for treating ocular herpes. Clin Ophthalmol. 2007;1:441-53.
Bacterial Conjunctivitis Treatment
• Fluoroquinolones
– Besifloxacin
– Levofloxacin
– Moxifloxacin
– Gatifloxacin
– Ciprofloxacin
• Macrolides
– Azithromycin
[1] Marangon F.B., et al. American Journal of Ophthalmology, 2004. 137(3): 453-458. [2] Prost M, Semczuk K. KlinOczna, 2005. 107(7-9): 418-420. [3] Gaynor
BD, Chidambaram JD, Cevallos V, et al. Br J Ophthalmol. 2005 Sep;89(9):1097-9. [4] Iihara H, Suzuki T, Kawamura Y, et al. Diagn Microbiol Infect Dis. 2006
Nov;56(3):297-303. [5]Uchio E, Takeuchi S, Itoh N, et al. Br Ophthalmol. 2000 Sep; 84(9):968-72. [6] Silverman M, Bressman B. Conjunctivitis. Available at:
http://www.emdicine.com/emerg/topic110.htm.
Prevalence of Allergy
• A nationwide survey found that more than half
(54.6%) of all U.S. citizens test positive to one or
more allergens.1
• Allergic diseases affect as many as 40 to 50 million
Americans.2
Conjunctivitis Treatment
• Allergic
–
–
–
–
–
–
OTC agents
Antihistamines
Mast cell stabilizers
Combination antihistamine/mast cell stabilizers
Non-steroidal anti-inflammatory agents
Corticosteroids
• Greater than 70% of patients with systemic allergy
may manifest ocular symptoms.3
1
Arbes SJ et al. Preval
ences of positive skin test responses to 10 common allergens in the U.S. population: Results from the Third National Health and
Nutrition Examination Survey. J Allergy Clin Immunol. 2005; 116:377-383. .
2 Airborne allergens: Something in the air. National Institute of Allergy and Infectious Diseases. NIH Publication No. 03-7045. 2003.
3 Katelaris CH, Bielory L. Evidence-based study design in ocular allergy trials. Curr Opin Allergy Clin Immunol. 2008;8(5):484-8.
17 | PAT12500SK
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Most Prescription Treatment Options Have
a
Limited Effect on the Inflammatory Cascade
Early-Phase
Mediators
Ocular Allergy Complications
• Unpredictable Refractive Results
• Diffuse Lamellar
Keratitis
• Chronic Cystoid
Macular Edema
• Conjunctival Scarring
• Corneal Opacity & Ectasia
• Trichiasis Entropion
• Corneal Ulceration
Late-Phase
Mediators
Mast Cell
Membrane
Phospholipids
Mast Cell Stabilizers (MCS)1
Work Here
Phospholipase A2
Activity
Arachidonic Acid
Combination
Antihistamines/MCS1
Work Here
Histamine Heparin Proteases
(tryptase, chymase)
Antihistamines 1
PAF
Cyclooxygenase
Pathway
NSAIDs
Work
Here
Cyclic Endoperoxides
Lipoxygenase
Pathway
Hydroperoxides
(5-HPETE)
Work
Here
Prostaglandins Prostacyclin Thromboxane A2
HHT, MDA
(PGF2α, PGD2, PGE2) (PGI2)
(TXA2)
Leukotrienes
(LTC4, LTD4, LTE4,
LTB4)
1. Adapted with permission from Donnenfeld ED. Refract Eyecare. 2005;9(suppl):12-16.
2. Slonim CB. Rev Ophthalmol. 2000:101-112.
Point of Service Allergy Testing
Allergy Antigen Testing
• Cutaneous Skin Prick Test
• Tear IgE
–
–
–
–
– Advanced Tear Diagnostics (Birmingham, AL)
– Rapid Pathogen Screening (Sarasota, FL)
– TearLab (San Diego, CA)
Must stop anti-histamine Rx
Dermatitis or eczema may preclude testing
Risk of severe specific allergic reaction
Less suitable for infants and children
• RAST (Radioallergosorbent Test) Pharmacia patent
• ImmunoCap Specific IgE Test
• Skin Testing
–
–
–
–
– Allergy Corp Group (Charleston, SC)
– Doctors Allergy Formula (Norcross, GA)
New Gold Standard in 2010
Not as sensitive as Skin Testing
More costly than Skin Testing
Delayed results
21
Who Should Be Tested?
• Recurrent or chronic URD, i.e., rhinitis, sinusitis,
allergic-rhinitis
• Unseasonal allergy-like symptoms
• Seasonal or perennial allergy-like symptoms
• Recurrent otitis media
• Exogenous asthma and other conditions in which IgE
mediation is suspected
22
Serum and Skin
Prick Test Comparison
Key Allergy Test Differences
Blood Test
Skin Prick
Ordered in PCP or ECP office
Yes
Yes
OK to stay on allergy medication
Yes
No
Only one needle stick
Yes (blood draw)
No (60)
No risk of severe allergic reaction
Yes
No
OK with skin rash present
Yes
No
Children as young as 3 months
Yes
No
Same day results in the office
No
Yes
24
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ANTIGEN SKIN TESTING
Specific Allergy Therapy
CPT 95004
•
•
•
•
•
Preventive
Palliative
Alternative
Immunotherapy
Pharmacologic
– Topical, Nasal, Inhaled
– Dermatologic
– Systemic
26
Graded Pharmacotherapy
Stepwise Treatment Strategies for Allergic Conjunctivitis
Avoidance, cold compresses, tears, over-the-counter medications
Mild
Topical antihistamines/mast cell stabilizers
Oral antiallergics (allergists may already have patients on orals;
may exacerbate the ocular condition while improving the nasal condition)
Montelukast
Moderate
+ Mast cell stabilizers (treats allergy before mediator is released)
+ Combination antihistamine/mast cell stabilizers
+ Topical corticosteroids (most beneficial for severe outbreaks)
Severe
Topical corticosteroids (short course;
fluorometholone/dexamethasone/loteprednol/prednisolone)
Topical immunomodulating agents (tacrolimus, cyclosporine)
Oral steroids
•
•
•
•
•
•
•
•
•
•
•
•
12 Patient Allergy Tips
Never rub your eyes
Wash your hands
Use allergy free pillows
Stay indoors
Use drops for eyes, sprays for nose
Avoid “get the red” out vasoconstrictors
Chill your drops
Use cool compresses
Apply allergy drops proactively
Pets out of the house or bedroom
Know and avoid your personal antigens
Try Montelukast: no sedation, no drying
28
Case Study
• 2/13 ROV: 52 YO Asian Female / Follow up 4
month dry eye check. Intermittent foreign
body sensation and fogged vision over 1 year
• Ocular Hx: DES, LASIK 12.08.11
– Ocular Medications: Restasis BID OU
• Medical Hx: Allergies, Borderline Diabetes, Acid
Reflux
– Systemic Medications: Multivitamin, Iron
Slit Lamp Examination
• BCVA
– OD 20/25– OS 20/20-
• MR
– OD pl – 0.75 x 005
– OS -0.50 DS
• External: normal OU
• Conjunctiva: 2+ injection
• Cornea: 1+ Diffuse SPK
OU
• Tear Eval:
– 4 sec NIBUT
– Schirmer 8/9
• Iris: flat OU
• A/C: deep & quiet OU
• Lens: clear OU
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Diagnostic Testing
• Definition
•
•
•
•
Clinical history
Symptom questionnaire
Tear film break up time
Ocular surface staining
•
•
•
•
•
Schirmer / Red Thread Test
Lid and meibomian morphology
MG Expression
Tear meniscus
Tear film osmolarity
– Nafl / Lissamine Green
SLK and Treatment
•
•
•
•
•
•
•
•
Lubrication
Acetylcysteine
Mast cell stabilizers
Steroids
Cyclosporin A
Soft contact lens
Silver nitrate
Autologous serum
Superior Limbic Keratitis
• Botulinum toxin
• Supratarsal steroid
injection
• Resection
• Conjunctival ablation
• Consider thyroid
evaluation
Example of Culture Report
• Pathogenesis
– Uncommon chronic disease
– Superior bulbar and tarsal
conjunctiva and limbus
– Bilateral
– Middle aged women
– Abnormal thyroid function
– Symptoms worse than signs
– Remission occurs
spontaneously
– Blink-related trauma
– Tear film insufficiency
– Excess of lax conjunctival
tissue
– Inflammatory process
– Self-perpetuating cycle
Eyelid / Conjunctival Cultures
• Eyelid
– Moisten swab, rub along the lid margins
• Conjunctiva
– Inferior palpebral conjuntiva
• Inoculate solid media plates
• Culture
– Calcium alginate swab
– Cotton-tipped applicator
– Transport medium
Demodex Mite
• Hold for:
– Bacteria 1 week
– Viral 2 weeks
– Fungal 1 month
• Test for all sensitivities
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8/25/2014
Demodex
• Life Cycle 14 ½ Days
• .1mm to .4mm
• Demodex Brevis
– Live in Sebaceous Glands Connected to Hair Follicles (Zeis)
• Demodex Folliculorum
Increases of Demodex with Age
•
•
•
•
•
13% of subjects 3 to 15 years
34% of subjects 19 to 25 years
69% of subjects 31 to 50 years
87% of subjects 51 to 70 years
95% of subjects 71 to 96 years
– Live in the Eyelash Follicles and Meibomian Glands
• Move at 1cm Hour
• Avoid Light and Migrate at Night
Czepita D, Kuzna-Grygiel et al. Investigations of the occurrence as well as the role of
Demodex Folliculorum and Demodex brevis in the pathogensis of blepharitis 2005.
Demodicosis
•
•
•
•
•
•
Dry Eyes
Itching
Scaling of Lids
Decreased Vision
Madarosis
As a result of blockage of follicles and
hyperkeratinization and epithelial hyperplasia
Demodex
• Linked to Some Forms of Rosacea
• Mating at Night in Hair Follicle
• Eggs are Laid Deep Inside Sebaceous and
Meibomian Glands
• Larvae Hatch in Glands 3-4 Days
• Develop Into Adults 7 Days
Demodex Diagnosis
• Observation Under Light Microscope of Lash
Follicle
• Small and Translucent
• Often Diagnosis of Exclusion
• Need Reliable Clinical Tests
Case Study
•
•
•
•
•
•
•
54 Year Old Female
History of Pernicious Anemia
Hypo Thyroid (Synthroid)
HRT
B-12
Prozac
2 year hx of Severe Dry Eye Syndrome
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Case Study
• Full Scope Treatment of OSD
Case Study
• Full Scope Treatment of OSD
– Plugs Lower and Upper (Upper removed)
– Lid Hygiene
– Progressing over 4 years in therapy
– Various Artificial Tears – Currently with HA
– Restasis
– Lotemax
– AzaSite
• Sterilid (marked improvement that gradually diminished)
– Doxycycline
– Thera Tears Nutrition
Conventional Treatment Methods Are Not
Effective in Managing Demodex Blepharitis
Case Study
• Full Scope Treatment of OSD
– Autologous Serum (Got worse after 1 week)
– Worse at Night (no Nocturnal Lagophthalmos)
– Itching
– Discussion of Demodex
•
•
•
•
Cannot be killed by Baby shampoo (common lid hygiene)
Cannot be killed by 10% Propidone iodine (surgical scrub)
Cannot be killed by 75% alcohol
Cannot be killed by Macrolides such as erythromycin
(antibiotic)
• Cannot be killed by Metronidazole (for Rosacea treatment)
• Cannot be killed by 4% Pilocarpine (for lice treatment)
• Killed dose-dependently by Tea Tree Oil (TTO), derived from
Melaleuca alternifolia
Tea Tree Oil
•
•
•
•
•
•
Compounding Pharmacy
50% Solution of Tea Tree Oil
20% Solution of Tea Tree Ointment
Tea Tree Shampoo
Tea Tree Soap
Cliradex
Tea Tree Oil
• Begin Application of Tea Tree Lotion at Night
on Face/Lids/Lashes
• Office Visit
– 4% Lidocaine Applied to Base of Lashes
– 50% Tea Tree Oil Applied to Base of Lashes
– Repeat X 2 in 10 Minute Intervals
– Lotemax qid
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Demodex
Case Study
• Began Resolution Within 2 Days
• Tapered Steroid over 3 days
• “First time in over 2 years that I haven’t felt
my eyes”
• Linens
• Treat Husband
Case Study
• 3/27/12 Increased light sensitivity / pain OU
– Dx: Rebound Iritis OU
– Tx: Restart difluprednate and nepafenac TID OU
• 5/14/12 F/u chronic iritis OU, FBS OS
– Dx: Improved Chronic Iritis OU, Dry eye disease
OS>OD
– Tx: Decrease steroid and NSAID to BID OU, ATs BID
OU
Understanding Tear Film Instability
in Dry Eye
• 72 YOAAF – Referred by OD for Cataract Eval
OU. Blurred VA. Occasionally uses ATs prn.
• Med Hx of allergies, acid reflux and HTN
• SLE: 3+ NS OU
• Uneventful cataract sx OU
– OD 1/4/12
OS 2/1/12
Case Study
• 9/7/12 – F/u chronic iritis, FBS OS>OD, Tearing
– Dx: Resolved iritis OU, Dry eye disease OU
– Tx: Start on cyclosporine 0.05% OU, F/u 4-6 mos
• 2/25/13 – F/U dry eye disease OU, OS always has a
FBS, Chronic tearing
– Dx: DED OU / See photo
– TearLab: 298 / 301
Osmolarity & Tear Film Instability in
DED
• Normal subjects exhibit low and stable osmolarity
– Normal tear osmolarity = 280 - 300 mOsms/L
– Equivalent to blood osmolarity = 285-300 mOsms/L
– Indicative of the tears being held in proper homeostasis
• Dry Eye subjects exhibit elevated and unstable osmolarity
– Osmolarity changes between eyes and over time
– Variability is the hallmark of DED ( > 8 mOsms/L between eyes)
• Osmolarity was found to be the least variable of all common
signs1
– Osmolarity: 8.7%
– Corneal Staining: 12.2%
– Conjunctival Staining: 14.8%
– Meibomian Grading: 14.3%
– TBUT: 11.7%
– Schirmer’s Test: 10.7%
1Sullivan BD,
Crews LA, Sönmez B, de la Paz MF, et al. Cornea 2012
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InflammaDry
Advanced Tear Diagnostics
Tearscan
Referred to Conjunctival Resection
• Dx: Conjunctivalchalasis OS>OD
• Tx: Schedule for conjunctivoplasty OS
– Disc R/B/A to surgery including 50% chance that
symptoms will not improve even after a successful
operation.
– Pt elected to proceed with conjunctivoplasty OS only,
as that is the more symptomatic eye.
Case Example
• 39 year old female
• Presents for a frequent burning sensation OU
– Most often in the morning with complaints of
dryness that blinking helps
– Also notes redness with blisters around eyelids
• Ocular Medications
– Systane Q1H OU
– Elidel applied to eyelids BID
Medical History
• Review of Systems
– Sinus problems
• Systemic Medications
– Spironolactone, Singulair, Flonase, Baby Aspirin
• Family Health
– Hypertension – Mother
• Social History
– Never smoked, 1 glass of wine daily, 1 cup of
caffeine daily
Exam
• VA cc
– OD: 20/20-1 OS: 20/20-1
• Pupils, EOMs and Confrontation fields all
normal
• Adnexa
– 2+ Erythema of the lids
– Vascularization of the lid margins
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Slit Lamp Exam
•
•
•
•
•
•
•
Conjunctiva: 2+ inferior limbal injection
TBUT of 3 seconds
Schirmers 30/17
Cornea: 2+ SPK OU, Few limbal infiltrates
Anterior Chamber is deep and quiet
Iris normal
Lens is clear
Impression and Plan
Case Example - PB
• 3 Weeks Later – mild improvement
• SLE – Improved Lids / Conj / Cornea
• Plan:
• Blepharitis and Staph Hypersensitivity
• Ocular Rosacea
–
–
–
–
–
–
–
Continue Systane PRN
Start Doxycycline 50mg BID PO
Warm compresses BID OU
Loteprednol 0.5% / tobramycin 0.3% TID OU
Loteprednol 0.5% ung PRN OU
Fish Oil 2000mg PO
Consider cyclosporine 0.05% at next visit
– D/c loteprednol / tobramycin
– Start cyclosporine BID
– Cont systane
– Cont doxycycline 50 mg po
– Fish oils 2g per day
– Warm compress qhs
– Consider Lipiflow treatment
• RTC 3-4 weeks for follow up appointment
LipiFlow® Thermal Pulsation System
Don’t Have $100,000
for a LipiFlow?
LipiFlow safely and effectively treats Meibomian gland obstruction in both
upper and lower eyelids simultaneously, in an in-office procedure, taking
only 12 minutes per eye
65
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8/25/2014
MiBoFlo ThermoFlo®
Meibomian Duct Therapy
Meibomian Gland Treatments
Nocturnal Lagophthalmos
• Typical Patient
– Has progressed as a dry eye patient
– Has little response to traditional treatment
– Often doesn’t realize lagophthalmos
– Sandy gritty feeling in the morning
– Feels the need for artificial tears upon waking
– Slight photophobia
– Feels better after a shower
Noctural Lagophthalmos
Noctural Lagopthalmos
• Ask Every Dry Eye Patient “how do your eyes
feel first thing in the morning when you wake
up?”
• Ceiling Fans at night?
• Look for lid closure
• Children
• Solutions:
– Ointments, gels, weights, tape
– Tranquileyes, Lacriserts
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Case Study - CH
•
•
•
•
•
•
07/06/09
54 YOMW / Referred from OD for K Ulcer
Started on levofloxacin 0.5% Q1h OS
Pain and Redness started 5 days prior
SCLW / Denies sleeping in lenses
VAcc OD 20/60 OS 20/200
Infectious versus Sterile
• Infiltrate
• Ulcers
–
–
–
–
–
–
–
–
Rare
Painful
AC reaction
Usually single lesion
Discharge
Epithelial staining
Corneal edema
> 2.0 mm in size
–
–
–
–
–
–
–
–
Common
Mild pain
No AC reaction
Multiple lesions
Minimal discharge
Epithelium intact
No corneal edema
< 2.0mm in size
Fungal Keratitis
Case Study
•
•
•
•
•
3 + injection
3.5 mm ulcer
2+cells
Cultures taken
Added tobramycin Q2h
Bacterial Keratitis
Symptoms
• Pain
• Photophobia
• Redness
• Decreased vision
• Discharge
Signs
• Focal infiltrate
• Stromal loss
• Epithelial defect
• Lid swelling
• Hyperemia
• Mucopurulent discharge
• K edema
• AC reaction
• Poss. hypopyon
Acanthamoeba Keratitis
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8/25/2014
HSV Keratitis
Staph Hypersensitivity
7/7/09
7/9/09
• Cloudy since yesterday
• Labs – No growth
• SLE
– Conj - 4+ Injection
– Cornea - 3.5 mm ulcer / Haze / 1+edema / WBC
– A/C - Rare cell
• Plan
– Continue present meds
– Add sub-conjuctival injection of gentamycin
– Add loteprednol 0.5% tid OS
• More photophobic
• SLE
– Conj - 2+ Injection
– Cornea – 3.0 mm ulcer / 1+edema / WBC
surrounding ulcer
– A/C – D/Q
• See lab results
Steroids for Corneal Ulcer Trial
• Objective: To determine whether there is a
benefit in clinical outcomes with the use of
topical corticosteroids as adjunctive therapy in
the treatment of bacterial corneal ulcers
• Results: No significant difference was
observed
–
–
–
–
3-month BSCVA (P =.82)
Infiltrate/scar size (P = .40)
Time to reepithelialization (P = .44)
Corneal perforation (P > .99)
Srinivasan M, Mascarenhas J, Rajaraman R, Ravindran M, Lalitha P, Glidden DV, Ray KJ, Hong KC, Oldenburg CE, Lee SM, Zegans
ME, McLeod SD, Lietman TM, Acharya NR; Steroids for Corneal Ulcers Trial Group.
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Treatment
•
•
•
•
•
•
Primary goal – eliminate the pathogens
Secondary goal – prevent host destruction
Treated as bacterial initially
Small infiltrates – empirically (<1.0mm)
Discontinue CL wear
Cycloplegics
– Homatropine 5% tid
– Scopolamine 0.25% tid
– Atropine 1.0% tid if hypopyon present
Treatment
• Fluoroquinolones – standard
– Broad spectrum
– Bioavailability
– Biocompatibility
• Peripheral infiltrates – q1-2h
• Medium size – q1h w/ loading dose
• Vision threatening – Fortified antibiotics
– Tobramycin/gentamycin (15mg/mL) q1h
– Cefazolin (50mg/mL) or vancomycin (25mg/mL) q1h
– Fluoroquinolone
Antimicrobial Susceptibility
Surveillance: Ocular TRUST
Antibiotic Resistance Monitoring in
Ocular Microorganisms Study (ARMOR)
• 200 S. aureus and 144 CNS ocular isolates were
collected from 34 centers across the US.
• Of the S. aureus isolates:
– 39 percent were fluoroquinolone-resistant
– 39 percent methicillin-resistant
– 31 percent resistant to both
• Of the CNS isolates:
• Nationwide surveillance specific to isolates from
ocular infections
• Longitudinal data
• Ocular TRUST 2006-2008
– Fluoroquinolones most consistently active agents across
common ocular pathogens
– Gatifloxacin = Levofloxacin = Moxifloxacin
– 43 percent were fluoroquinolone resistant
– 53 percent methicillin-resistant
– 36 percent resistant to both
Asbell, PA. Sahm DF. AAO Poster PO066. Atlanta. November 8-9, 2008
Ocular TRUST Results
Ocular TRUST Results
Staphylococcus aureus In Vitro Susceptibility
Coagulase-Negative Staphylococci (CNS)
In Vitro Susceptibility
Methicillin-Susceptible S. aureus
Methicillin-Resistant S. aureus
Methicillin-Susceptible CNS
Key
Key
CIP, ciprofloxacin; GAT, gatifloxacin; LEV, levofloxacin; MOX, moxifloxacin;
AZTH, azithromycin; PEN, penicillin; PLX, polymyxin B; TOB, tobramycin;
TMP, trimethoprim
CIP, ciprofloxacin; GAT, gatifloxacin; LEV, levofloxacin; MOX, moxifloxacin;
AZTH, azithromycin; PEN, penicillin; PLX, polymyxin B; TOB, tobramycin;
TMP, trimethoprim
Asbell, PA. Sahm DF. AAO Poster PO066. Atlanta. November 8-9, 2008
Methicillin-Resistant CNS
Asbell, PA. Sahm DF. AAO Poster PO066. Atlanta. November 8-9, 2008
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Treatment
• Subconjunctival
injections
• Oral fluoroquinolones
–
–
–
–
– 0.3mg/dl lidocaine
– 0.3mg/dl gentamycin
• Topical steroid
Impending perforation
N. gonorrrhea
Ciprofloxacin 500 mg bid
Moxifloxacin 400 mg qd
• Admission to hospital
may be necessary
– Use w/ caution
• Oral pain meds
– Sight threatening
– Non-compliance
– If IV needed
– PRN
Case Example - BL
• 63YOWM Referred by PCP for sudden decrease VA OD
and swelling of eyelids OD>OS for 1 week
–
–
–
–
Pressure from forehead to cheek
Worse in evenings
Mild seasonal allergies
Some tearing and redness OD
• Bitten 3 weeks ago on top of the head while working
in the yard which become swollen that evening
• Went to PCP and given oral ABX which finished
yesterday
Diagnosis???
• Considerations:
– PCP told him he had an infection not shingles
– Episode started 3 weeks prior
• Treatment
–
–
–
–
Valacyclovir 1000mg TID po
Diflurprednate QID OD
Timolol 0.5% QAM OD
F/u 1 week
Follow-up
•
•
•
•
•
•
Daily evaluation
Taper with improvement
Modify treatment based on results of culture
If non-responsive, culture
Corneal biopsy may be needed
If impending / complete K perforation:
– Cyanoacrylate tissue glue
– K transplant, patch graft
Examination
• Non-healing scab on R forehead
• Conjunctiva: 2+ injection OD
• Cornea: 2+SPK, 2+ MCE, 1+ KPs, No dendrites
OD
• AC: 2+ Cells OD
• Lens: 2+ NS OD / 1+NS OS
• IOP: 31/13
Herpes Varicella-Zoster Virus
• Primary infections: Chicken pox
– Remains latent in dorsal root or other sensory ganglia after
primary infection
– May lie dormant for years to decades
• Later infections: Shingles
– Virus specific cell-mediated immune responses decline
– Localized cutaneous rash erupting in a single dermatome
– HZO accounts for 10-25% of all cases of shingles
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Herpes Zoster Ophthalmicus
• 90% of U.S. population infected with VZV by
adolescence
• 100% of U.S. population by 60 years of age
• 1.5-3.4 cases per 1,000 individuals
Herpes Zoster Ophthalmicus
•
•
•
•
•
•
•
•
•
•
•
Conjunctivitis
Scleritis
Pseudodendrites
Keratic precipitates
Iritis
Synechiae
Neurotrophic keratitis
Elevated IOP
Potential vascular occlusion
Nerve palsies
Glaucoma (longer-term)
http://emedicine.medscape.com/article/783223-overview#aw2aab6b4
HZO: Signs and Symptoms
• Prodromal phase: fatigue, malaise, low-grade fever
• Unilateral rash over the forehead, upper eyelid, and nose
– 60% of patient have dermatomal pain prior to rash
– Erythematous macules to papules to vesicles to pustules to
crusts
– Other symptoms: eye pain, conjunctivitis, tearing, decrease VA,
eyelid rash
– Hutchinson’s sign
HZO: Treatment
• Local wound care
• Analgesia
• Antivirals
– Valtrex 1g TID
• Post-herpetic neuralgia
– Tricyclic antidepressants
– Topical capsaicin ung
– Gabapentin
• Antibiotics??
• Oral corticosteroids
• Post-herpetic neuralgia: >12 months for 50%
Vaccines for HZO - Zostavax
• Zostavax is live attenuated herpes
zoster (HZ) virus
– >50% reduction in the incidence of HZ
– >60% reduction in symptom severity in
patients who developed HZ
– 66.5% reduction in postherpetic
neuralgia.
Case Example - AM
• 44yo Asian American c/o blurred VA, redness,
tearing, peri-orbital edema starting 2-3 days prior
• Med Hx: Uncontrolled DM (Dx in 1998)
• Must have chicken pox as a child
• Vasc: OD 20/60 PH 20/30
OS 20/80 PH 20/40
• May help patients who've had HZO
already
• IOP: 21 / 18
1. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older
adults. N Engl J Med. 2005 Jun 2;352(22):2271-84.
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What is Your Treatment?
• Prednisolone acetate 1% vs. diflurprednate 0.05% vs.
loteprednol etabonate .5%
• Homatropine 5% vs. Scopolamine 0.25% vs. Atropine 1%
Case Example
• Acute, non-granulomatous, anterior uveitis OS
• Cause???
• Treatment
– Ordered labs – CBC w/diff, ESR, SMA-12, HLA-B27,
Urinalysis, FTA-ABS, RPR, Lyme Western Blot
– Diflurprednate q2h OS
– Homatropine 0.5% TID OS
– Doxycyline 100 mg BID po
• Would you prescribe an oral medication?
• Would you consider lab testing?
When Should Lab Tests Be
Ordered?
Uveitis: Common Systemic
Associations
• Bilateral cases
• Hyperacute cases
• Most common cause
• Atypical age group
• Worsens with tapering
• Other systemic causes
– Idiopathic : 38-70%
– HLA-B27 related disease
• Recurrent uveitis
• VA worsens
• Recalcitrant cases
• Immunosuppressed
•
•
•
•
–
–
–
–
Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Inflammatory bowel disease
Sarcoidosis
Systemic Lupus Erythematosus
Rheumatoid Arthritis
Behcets Disease
Photo accessed from http://www.aao.org/theeyeshaveit/red-eye/images/anterior-uveitis.jpg
Lab Testing
• Minimum lab testing
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–
–
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–
–
–
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–
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CBC with differential
Erythrocyte sedimentation rate (ESR)
Angiotensin converting enzyme (ACE)
Venereal disease research laboratory (VDRL)
Fluorescent treponemal antibody absorption (FTA-ABS)
Lyme titers in endemic areas
HLA-B27
Antinuclear antibody (ANA) test
Urinalysis
Chest X-ray
PPD
Pulse Therapy
•
•
•
•
•
QID to Q 1 Hour for 7 to 10 Days
Zero Tolerance for AC Cells
Avoids Surface Toxicity
Quick & Dirty
Hit It Hard and Fast: Aggressive
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Uveitis Take Home Pearls
Conclusions
• Be a detective and find the cause
• Practice to the fullest extent of our profession
• Be aggressive with treatment
• Be a detective
• Don’t taper too soon
• Think horses, not zebras
• Treat and follow
Thank You!
Walter O. Whitley, OD, MBA, FAAO
wwhitley@vec2020.com
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