Case 4: Keratitis

Question 1

Classic description of staph marginal keratitis

Answer 1

Mulitple, bilateral, peripheral corneal stromal infiltrates (w/o overlying epi defects) secondary to chronic blepharitis

Question 2

Corneal ulcer

Answer 2

Corneal epi defect w/ an underlying stromal infiltrate

Question 3

Recurrent corneal erosions

Answer 3

Poor hemidesmosome attachments between corneal epi & underlying basement membrane

Question 4

RCEs are most common in eyes w/ a Hx of ______or ______ ______

Answer 4

Trauma; corneal dystrophies

Question 5

What would a pt w/ an RCE report?

Answer 5

Pain in the morning upon awakening, photophobia, FB sensation

Question 6

50% of pts w/ RCEs have ______, only 10% of pts w/ _____ will develop RCEs

Answer 6

EBMD, EBMD

Question 7

Corneal abrasion

Answer 7

Occur secondary to trauma that results in corneal epi defect WITHOUT an underlying infiltrate

Question 8

Infectious corneal ulcers

Answer 8

The size of the epi defect will match the size of the infiltrate

Question 9

Sterile corneal ulcers

Answer 9

Epi defect will be smaller than size of the infiltrate

Question 10

Staphylococcus marginal keratitis is a type ______ hypersensitivity reaction

Answer 10

3

Question 11

What is staph marginal keratitis most commonly assoc w/?

Answer 11

Staph bleph, acne rosacea, & phylctenule

Question 12

Which inflammatory bowel disease most commonly is assoc w/ uveitis?

Answer 12

Ulcerative colitis

Question 13

IBD is most commonly assoc with what type of uveitis?

Answer 13

Acute, bilateral, anterior or posterior, non-granulomatous uveitis

Question 14

MC systemic sx of IBD

Answer 14

chronic diarrhea w/ alternating episodes of constipation, cramping & feeling bloated after meals

Question 15

What is most appropriate to treat staph marginal keratitis?

Answer 15

Topical ophthalmic antibiotic/steroid combo (Tobradex)

Question 16

Anterior Blepharitis Tx

Answer 16

1. eyelid scrubs BID or TID until the condition stabilizes, & then QD thereafter 2. Bacitracin or erthromycin ointment at bedtime for approx 2-4 weeks 3. Azasite (topical ophthalmic azithromycin) drops BID x 2 days then QD x 12 days 4. Topical ophthalmic antibiotic/steroid combination ointment at bedtime if sig redness or inflammation is present

Question 17

Posterior blepharitis Tx

Answer 17

1. warm compress 5-10 min QID 2. eyelid scrubs BID or TID until condition stabilizes, then QD after 3. topical opthal antibiotic/steroid combo (Tobradex) 4. Azasite BID 2 days then QD x 12 days 5. Oral doxy 100 mg BID for 4 wks, then 100 mg QD for 3-6 mo. or 40-50 mg QD for 6-12 mo. 6. Fish oil + omega 3 fatty acids

Question 18

Seborrheic blepharitis

Answer 18

Less eyelid inflammation, more oily, greasy scales, & flaking compared to staph bleph

Question 19

What are 3 objectives for RCEs?

Answer 19

1. Prevent infection & heal the corneal defect 2. reduce pain 3. prevent occurences

Question 20

3 ways to prevent infection & heal corneal defect in RCE

Answer 20

1. broad-spectrum topical opthal antibiotic BID to QID 2. preservative-free AT up to Q1H 3. debridement

Question 21

3 ways to reduce pain of RCE

Answer 21

1. cycloplegic 1 gt in office 2. topical opthal NSAID BID x 2-3 days or until corneal epi heals 3. bandage CL

Question 22

2 ways to prevent occurrence of RCE

Answer 22

1. oral doxy 50 mg BID & topical opthal steroid TID x 3-4 wks 2. muro 128 ointment qhs x 3mo.

Question 23

Anterior stromal micropuncture

Answer 23

making numerous micropunctures into & thru the corneal epi BM/Bowman’s layer complex -> SL w/ blunt stromal micropuncture needle

Question 24

What is the MC type of infectious keratitis?

Answer 24

Bacterial keratitis

Question 25

Canadian National Hockey League- bacteria that can invade an intact corneal epi

Answer 25

Corynebacterium diphtheria, Nisseria gonorrhea & meningitidis, Haemophilus, Listeria

Question 26

Tx of small corneal ulcers

Answer 26

Topical ophthal antibiotic Q1-2H after initial loading dose followed by slow taper

Question 27

Tx of large sight-threatening ulcers

Answer 27

Fortified topical opthal antibiotics (cephazolin 50 mg/mL & tobramycin 14 mg/mL every 15-30 min after a loading dose of 1 drop every min for 5 min

Question 28

Fungal keratitis presentation

Answer 28

Gray-white corneal infiltrate w/ feathery edges & satellite infiltrates

Question 29

Fungal keratitis Tx

Answer 29

Topical opthal antifungals Q1H while awake (Amphotericin B & Natacin). Systemic antifungals advised in severe cases (Ketaconazole, Itraconazole)

Question 30

Acanthamoeba keratitis presentation

Answer 30

Severe pain that is out of proportion to corneal signs in early stages of keratitis. Corneal signs include mild SPK & pseudodendritic defects.

Question 31

What culture does acanthamoeba keratitis grow on?

Answer 31

Culture requires a non-nutrient agar w/ Eschericha coli; acanthamoeba can also grow on blood or chocolate agar but not as well

Question 32

Acanthamoeba keratitis Tx

Answer 32

1. Topical opthal anti-parasitic agents: Propamidine isethionate Q1H (Brolene and/ or polyheamethyl biguanide PHNB) Q1H, followed by slow taper (often over the course of months. 2. oral anti-fungal agents: ketaconazole 200 mg or itraconazole 100 mg BID 3. cycloplegic agent TID 4. topical opthal antibacterial agent: Neosporin Q1H 5. topical opthal anti-inflammatory agents: topical opthal steroids (controversial)

Question 33

When is the FU for corneal ulcer?

Answer 33

1 day