Lecture 6 part4 PDF

CLPU 103 It can be an isolated infiltrate There is space between infiltrate and limbus Second picture à show a band of CLPU close to the limbus regions and haziness due to the wbcs being delivered 103 CLPU Signs & Symptoms Symptoms – Sectorial conjunctival Redness – + pain – + tearing – + FB sensati...

CLPU 103 It can be an isolated infiltrate There is space between infiltrate and limbus Second picture à show a band of CLPU close to the limbus regions and haziness due to the wbcs being delivered 103 CLPU Signs & Symptoms Symptoms – Sectorial conjunctival Redness – + pain – + tearing – + FB sensation Signs – – – – Peripheral cornea 1.0mm diameter, loss of entire epi layer equal in size to underlying ulcer Deep down to anterior stroma Ring of infiltration surrounds wound, Hypopyon Excessive Mucopurulent discharge Swollen lids, Meaty & chemotic bulbar conj Rapid onset Blurred vision due to the location of ulcer Photophobia Moderate to severe pain Increased incidence w/ EW or CW Pseudomonas most common organism 109 Peripheral ulcer is 1mm to 1.5mm and microbial ulcer is larger than 1-1.5 Location and size differeciates the peripheral ulcer and the microbial keratitis There is more loss of epi tissue that’s detsoryed by the bacteria and it is deeper than peripheral ulcer and its into the stroma. It will go deeper into the stromal layer compared to peirphral ulcer The history that leads upto the ulcer is abuse of cl and leaving the cl for some period of time and the epi becomes compromised form the toxic env and bacteria takes over 109 Case # 4 56 y F 30 years successful SCL DW 24 hrs ago OS onset FB sensation This AM – Decreased Va – OS bulbar injection – photophobia In Florida 10 days ago, canoeing, swimming recalls poked in eye with branch while canoeing 110 He has been in water à bacterial or fungal or acanthamoeba Signs & Symptoms OS Va: 20/40 (prev 20/20) + Clear Tears OS Mild/Moderate Nasal Bulbar hyperemia Whitish – Grey Epi ulcer, Stellate or fluffy bordered infiltrate, satellite lesions (+) Epi staining (+) hypopyon Surprisingly only Mild / Moderate pain 111 111 What is it ? 112 Initially it looked like this and there was a small area of haze and some infiltration around it 112 Fungal 113 Later on this was the appearance and it had feathery presentation compared to the corneal ulcer which is more defined in its border The microbial ulcer has depth and it has distinct border compared to fungal infection There is a epithelial statining and you don’t have excavation of the epi and anterior stroma. The staining is over the area of ulcer but not the depth you see in microbial Fungal can be centrally located 113 Key Factors:Fungal Keratitis Central corneal ulcer down to stroma Early presentation very similar to microbial kertatiyis Relatively quiet eye with Hypopyon – Non-CL wear: recent trauma by vegetative, soil, organic matter – SCL wear: poor hygiene, poor lens care, lens abuse – SCL wear Exposure to contaminated water (pool, ocean, well or city shower water) Recent exposure to Humid climate Surprising only Mild / Moderate pain Most common fungi; – Fusarium – Aspergillus 114 The eye is quiet in terms of pain and redness Pt has less pain compared to the presentation à making you think its more likely to be fungal Pts was exposed to vegetative matter making you think its fungal and not bacterial 114 Key Factors:Fungal Keratitis 115 Often times pts get a broad spectrum fortified antibiotics thinking its early presentation of microbial and to address the bacterial aspect but with time there is worsening despite the use of antibitoics and it gives you an idea it is fungal and not microbial For these patients à the scarping that was done will come back with fungal results in 2 weeks from lab and overtime there is progression of the ulcer and there is satellite lesion that protrude unlike microbial and they get worse with the antibiotics that is given 115 Fungal Diagnosis Immediately ID w Confocal Microscope – Only found in research setting of OMD residency hospitals Scraping & culture takes 2 weeks Monitor daily until cultures come back 116 116 2006 Fusarium Outbreak Feb 2006 Hong Kong & Singapore signif # of SCL pts reported having Fusarium infection March 2006 CDC reports 3 NJ SCL pts with Fusarium infection June 2006 CDC reports 318 cases across 33 states w/ Fusarium infection Common feature: B&L Renu Moisture Loc à fungal outbreak. The wetting 117 agent was contaminated in the solution 117 2006 Fungal Keratitis Outbreak Bausch & Lomb Renu Moistureloc Accumulation within solution bottle Pt poor hygiene practice No lens rub Topping off solution in case Biofilm formation on SCL allowing fungus to be protected on lens surface Incubation period of Fusarium is unknown. 118 Pts were also non-compliant and they were not eliminating the presence of the fungal that was on the lens was not removed with the rubbing Topping off à adding more mps solution over the old one so amount of fungus increased 118 Prevent Fusarium in CL Pt B&L Renu Moisture Loc removed from market Avoid water of any kind during scl wear Recommend – Regular lens replacement à daily/monthly/2wks – Monthly case replacement à every 3 months – Rub lenses with disinfectant before over night soaking à minimize fungal infection – No topping off (adding to solution already in case) Hand washing before lens removal (after opening case) 119 Avoid ocular contact with vegetative matter 119 Hx of trauma from plant matter à associated with fungal infection More common in tropical/moist climates Exposure to stagnant water Central infiltrate with branched extending outward & development of satellite lesion 120 120 Treatment: Topical Anti-Fungal Meds Polyhexamethylene biguanide (PHMB) à preservative in B&L products and higher dose is being used in the eye to treat the fungal infection Natamycin 5% (also cycloplega) Amphotericin B (q 30 min/24hr, q60min/24hr) Fortified Antibiotics à used due to the open wound but it’s the antifungals that eliminate the keratitis Alternating drops q30 minutes until lesion reduced in size Poor penetration so corneal debridement needed Maintain regiment for 14 days, then taper over 4-8 weeks à regiments is long Scarring effect on vision ? Possible PKP à depending on the location of the scar after the keratitis they may need corneal transplant 121 121 Fungal growth on a SCL 122 122 Fungal Growth on SCL 123 123 Case # 5 Over whelming Pain 28 yo M 10 years successful SCL wear Reports both DW & EW of SCL Onset of Sx 4 days, rapid onset, serious pain last 2 days, very photophobic now Grade 2+ bulbar injection Started while camping in Vermont, wore lenses EW for 7 days Was canoeing & swimming in lakes Typically stores lenses in pharmacy saline 124 There was significant pain and the eye was taped close Extended wear and exposure could have led to the contamination 124 What is it ? Stromal Dendritic Appearance absent end bulbs Ring 125 Infiltration presentation and it looked dendritic but there was no end bulbs Infiltration It seemd to follow the path of the nerve 125 Ring Shaped Infiltrate presents in 50% of cases 2-3 weeks s/p onset 126 The eye was in pain but the presentation was not concerning There was ring infiltrate 126 Serious Adverse: Acanthamoeba keratitis 127 And as it developed, it spread 127 Late Stage Acanthamoeba 128 It can become dense in its inflammatory response The ring infiltrate involving the corneal nerve à sign for acathoemeba 128 Observations Limbitis: Limbal inflammation at site Enlarged / engorged radial nerves as (amoeba mirgates alone nerves) – Dendrite like without end bulbs Mild Epi Punctate Keratitis over infiltrate Partial circle or dendritic stromal infiltrate Possible cells in A/C Pain seems dramatic for moderate signs because of corneal nerve inflammation 129 Infiltartes look like dendrites but no dnedirtes unlike herpetic infection There is A/C reaction and there can be hyphema Pain and ring infiltrate à indicates acanthoemoeba 129 Acantha Unique Sx’s & Signs Dramatic degree of Pain beyond signs Infiltrates along radial corneal nerves Dendrites with out end bulbs Partial or complete Ring infiltrate Iritis 130 In the microbial infection the eye looks worse and there is pain Here the eye does not look in pain but it is in pain and there is inflammation of the corneal nerves but in the ulcer it is on the cornea leading to the destruction of the epithelium 130 Acanthamoeba Keratitis Water borne amoeba found everywhere Water: fresh, well, sea, brackish, sewage, hot tubes, muddy water. Two forms – Cyst form (resistant to irradication) – Trophozite active form- infectious Confocal Microscope can detect cyst & trophozite in corneal tissue 131 131 Acanthamoeba K & SCL 80% of AK in SCL users with Poor compliance Hx of exposure dirt Hx poor hygiene – No hand washing, no disinfection Hx EW , CW – Lenghty exposure to AK contaminated lens Hx of exposure to water (shower, well, lake, sea, brackish, sewage, mud) 132 Exposure to contaminated water, extended wear of the lens Location of ulcer, appearance of the border, degree of pain à will help you isolate which is the proper diagnosis 132 Commonly Misdiagnosed Acanthamoeba Herpes Simplex Severe Pain Circular infiltrate Infiltrate along radial corneal nerves 80% wear SCL Hx of exposure to contaminated water Mild to moderate pain Linear infiltrate End bulbs CL wear not predisposing factor Unrelated to water exposure 133 Inflammation of nerve fibers and there is no end bulbs in acthaoemba compared to hepetic infection 133 Methods of Diagnosis Culture / Biopsy: Delayed result – Scraping & plating on non-nutrient agar – 3 days to 3 weeks to grow Confocal Microscope: Immediate Dx – Non-invasive examination of individual cornea layers – Micro-organism can be visualized – Visualization of inflamed nerves – Located major eye hospitals (NYE&E) 134 skip 134 Medical Treatment for AK No standardized treatment ( avoid steriod) Epithelial debridement Both Antiameoebic drugs Q 1h for 48 hours – Polyhexamidine biguanide – Chlorhexadine Fortified antibiotic drops Q 1 h for 48 hours Following three days continue regiment during waking hours Continue hourly regiment for 3 weeks. Taper over 2-3 months. Often, scarring necessitates PK 135 Avoid steroid à will lead to further development of the infection Fortified antibitoocs will be given Can take months to recover They have hazing and scarring of the cornea so transplant maybe needed and it is after the infiltration has been quiet down 135 Clinical Pearls Concerning AK Consider AK in SCL pt 1-2 wks unresponsive to topical meds Partial or complete Circular Infiltrate All Kinds of pain due to inflammation of corneal nerves Radial nerve infiltration Exposure of contaminated water Early referral to Corneal Sp @ medical center. 136 skip 136 Same 4 Risk Factors for all SCL complications Significant elevation of risk factors with Abuse or EW SCL, Poor lens care Swimming or Showering, SCL wear during illness Age & Gender: Poor hygiene, poor hand washing Smoking Manage these and reduce complications/ 137 skip 137