other corneal and conjunctiva infections and inflammations
Terms
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- what is the causitive organism for chlamydial infections
- chlamydia trachomatis ; an obligate intracellular parasite that is a genus of its own
- does chlamydia have viral or bacterial characteristics
- it has both viral and bacterial characterisitics
- what is the most common STD in the US
- chlamydia
- what are the two forms of chlamydia
- adult inclusion conjunctivitis and trachoma
- what is the most common form of chlamydial infections in the industrialized world
- inclusion conjuctivitis
- how does a person get adult inclusion conjunctivitis
- from sexual exposure
- s/s of adult inclusion conjunctivitis
- acute follicular and papillary conjunctivitis with scant mucopurulent discharge; nonsymptomatic genitally; PAN
- what is the incubation period of inclusion conjunctivitis
- 5-12 days
- what may inclusion conjunctivitis mimic
- EKC with SEI's
- which conjunctiva is more infected
- the lower palpebral conj more infected as oppose to trachoma
- what does cytology studies reveal
- monocytes and neutrophils
- what prompts suspecion of chlamydia
- red eyes non-responsive to standard therapy
- treatment for chlamydia
- azithromycin 1g QD(once a day) x 1 dose
- alternate treatment for chlamydia
- doxycycline 100mg BID 1st day , then 100 mg QD x 21 days
- in patients who are allergic use what
- tetracycline 250 mg QID x 21 days; erythromycin 500mg QID x 21 days; do not use doxycycline or tetracycline in children under 8 years old or in pregnant or lactating mothers
- what is the most common form of chlamydia in underdeveloped countries and rarely in the US (in southwest among native americans)
- Trachoma
- how is trachoma transferred
- from eye to eye via fly infestation
- what is the most common cause of preventable blindness or decreased vision in the world
- trachoma
- which conjunctiva is more infected in trachoma
- upper and lower palpebral and limbal follicles and papillae
- s/s of trachoma
- photophobia, tearing, mild mucopurulent discharge (secondary bacterial infection)
- what are ARLT's line
- they represent superior tarsal conjunctiva scarring and leads to entropion, trichiasis, and mucin-deficient dry eye from goblet cell destruction
- punctal stenosis and trachoma
- this is possible secondary to scarring but is rarely enough to combat the induced dry eye symptoms
- what are herbert's pitts
- a sign of trachoma, scarred limbal follicles -- small depressions around limbus -- diagnostic of trachoma
- main diagnostic signs of trachoma
- ARLT's line, Herbert's pitts, superior SPK, pannu, edema, punctal stenosis, entropion, trichiasis, mucin deficient dry eye,
- stage 1 of trachoma
- immature follicles on superior tarsus with minimal papillary hypertrophy, may see SPK or pannus
- stage 2 of trachoma
- follicular hypertrophy, limbal follicles, pannus, and corneal SEI's, Papillary hypertrophy, intensification of inflammatory response with obliteration of follicles by papillae, necrosis of follicles
- stage 3 of trachoma
- cicatrizing trachoma; ARLT's line, Herbert's pits, entropion and trichiasis may form
- stage 4 trachoma
- healed trachoma; inflammation has resolved and is replaced by scar tissue; no follicles or papillae; no SEI's; corneal involvement in the form of secondary bacterial keratitis may lead to blindness and results from corneal insult from trichiasis and scarring
- treatment of trachoma
- zithromax 1g QD x 1 dose; doxycycline 100mg BID for 1st day then 100 mg QD for 21 days; tetracycline 250 mg QID x 21 days, erythromycin 500 mg QID x 21 days
- Toxic and Irritative Follicular Conjunctivitis causes
- caused by long term use of certain ocular medications, heavy makeup use, environmental irritants, radiation, soaps, etc.
- which type of medication mostly causes toxic and irritative follicular conjunctivitis
- strong miotics
- toxic and irritative follicular conjunctivitis etiology
- may be due to toxic protein reaction or from hypersensitivity reaction
- s/s of toxic and irritative follicular conjunctivitis
- minimal mixed papillae and follicles; unilateral
- treatment for toxic and irritative follicular conjunctivitis
- switch ocular medications when possible, encourage better hygiene in heavy makeup users, remove irritants where possible, artificial tears for supportive therapy
- s/s of superior limbic keratoconjunctivitis
- chronic and recurrent inflammation of the superior palpebral and bulbar conjunctiva and cornea
- course of superior limbic keratoconjunctivitis last for how long
- several months to years
- etiology of superior limbic keratoconjunctivitis
- unknown
- where is there marked hyperemia in superior limbic keratoconjunctivitis
- in superior conjunctival and cornea with irritation
- where does the number of goblet cells increase in superior limbic keratoconjunctivitis
- palpebral conjunctiva
- where does the number of goblet cells decrease in superior limbic keratoconjuctivitis
- bulbar conjuctiva
- what systemic disease is superior limbic keratoconjunctiva associated with
- thyroid disease and dry eye
- what is the diagnostic sign for superior limbic keratoconjunctivitis
- rose bengal staining of entire area involved
- what is the area involved for superior limbic keratoconjuctivitis when using diagnostic sign
- bilateral but asymmetrical
- symptoms of superior limbic keratoconjucntivits
- FBS, photophobia, pain, may have filaments present
- Treatment for superior limbic keratoconjunctivitis
- Artificial tears, punctal occlusion, pulse of steroids, acetylcysteine (to break up mucus) drops, cromolyn sodium drops, 0.5% silver nitrate, bandage SCL, thermal cautery of conjuctiva, surgical conjunctiva resection (highly successful)
- what are the two types of phlyctenulosis
- conjunctival and corneal
- sign of conjunctival phlyctenulosis
- focal nodule of limbal tissue, inflammatory
- etiology of conjunctival phlyctenulosis
- in respones to staphylococcal exotoxins (staph bleph), less commonly TB (order chest x-ray)
- treatment of phlyctenule and staph bleph
- staph is almost always present so when treat this the phlyctenule also disappears
- treatment of phlyctenule
- vasoconstrictors or steroids/antibiotic combination drop if moderate to severe
- corneal phlyctenule s/s
- appears whitish plaque on the cornea itself; same associations as conjunctival variety
- ophthalmia neonatorium
- conjunctivitis in a neonate
- when might ophthalmia neonatorium occur
- 3-5 days postpartum (any time within a few weeks after birth is still considered ophthalmia neonatorium
- how many newborns are affected with ophthalmia neonatorium
- 12%
- what are the three routes of inoculation of ophthalmia neonatorium
- ascending infection from cervix and vagina secondary to a premature membrane rupture; mom has an infection in birth canal; postpartum contact
- what are the major organisms that cause ophthalmia neonatorium
- s. aureus, s. pneumoniae, s. pyogenes, h. flu, gonococcus, pseudomonas aeruginosa, chlamydia, gonococcal infection
- what is the leading agent for infectious neonatal conjunctivitis in the U.S.
- Chlamydia
- sign of ophthalmia neonatorium from chlamydia
- papillary response only, no follicular response bcs the lymph system is not fully developed until 4-5 months after birth; a mild to moderate mucopurulent exudate with lid edema, chemosis, and pseudomembrane formation, can cause pneumonitis
- which are more common causes of ophthalmia neonatorium bacterial or virus
- bacteria are more common causes; viral are less common but HSV can have severe ocular consequences, while CMV also has severe systemic complications
- prophylaxis treatment is mandatory in all states what is the treatment
- erythromycin 0.5% ung (effective against chlamydia and gonococcus), use to use crede's prophylaxis 1% silver nitrate (effective against gonococcus but causes toxic conjunctivitis)
- treatment for ophthalmia neonatorium chlamydia
- oral erythromycin 10-14 days
- treatment for ophthalmia neonatorium gonococcal
- IV cillin drugs x 7-14 days
- treatment for ophthalmia neonatorium non-gonococcal
- topical bacitracin ung with gentamicin solution 3-4 hours, tapered as response improves
- treatment for ophthalmia neonatorium HSV
- viroptic 1% drops every 2 hours up to 9 doses max daily taper dose as improvement occurs, continue treatment for a total of 3 weeks
- what is neurotrophic keratopathy
- loss of innervation to corneal tissue causing epithelial defect
- causes of neurotrophic keratopathy
- S/P infection by varicella zoster, HSV; stoke, complications of CN V surgery; complication of irradiation to eye or adjacent structure; tumor (acoustic neuroma)
- signs of neurotrophic keratopathy
- loss or reduction of corneal sensation; epithelial defects with fluorescein staining; perilimbal injection; possible corneal ulcer with associated iritis
- how does the ulcer look in neurotrophic keratopathy
- gray heaped up border, oval in shape, and is usually located in lower half of cornea
- symptoms of neurotrophic keratopathy
- red eye, FBS (inspite of reduced corneal sensitivity), swollwen eyelid
- workup for neurotrophic keratopathy
- careful history with attention on prior infections, injuries, surgeries, test corneal sensation (compare one eye to the other); look for signs of corneal exposure; CT/MRI if tumor is suspected
- treatment of neurotrophic keratopathy
- if mild lubricants; if corneal defect, treat as if corneal abrasion(antibiotic ung, cycloplege, pressure patch or bandage SCL); if this sterile ulcer becomes secondarily infected now you have a infectious corneal ulcer treat accordingly; tarsorrhaphy; bandage soft CL
- describe thermal / UV keratopathy
- damage to cornea from thermal burn or UV exposure; symptoms usually appear 8-12 hours following exposure
- etiology of thermal/uv keratopathy
- UV burns (sun, tanning bed, seen often in skiers, welders)
- symptomos of thermal/uv keratopathy
- moderate to severe ocular pain, FBS, Red Eyes, Tearing, Photophobia, Blurred vision
- signs of thermal/uv keratopathy
- confluent SPK in interpalpebral area (from squinting), conjunctival injection, eyelid edema, absence or minimal corneal edema, typically miotic pupils, may present as a droplet keratopathy
- what is a droplet keratopathy
- yellowish oily deposit in subepithelial cornea and conjuctiva
- treatment of thermal / uv keratopathy
- treat as if corneal abrasion: bandage SCL for mild cases, bilateral patching in severe cases, NSAIDs topical drops, 800 mg motrin over the counter
- Thygeson's Superficial Punctate Keratopathy describe
- coarse punctate epithelial keratitis of unknown etiology
- s/s of thygeson's disease
- photophobia, FBS, Tearing, Faint gray coarse PEK defects, usually round to oval and made up of miniscule opacities, bilateral, quiet white eye, strictly epithelial, no stromal involvement, usually chronic with recurrences for up to 30 years
- what does thygeson's disease stain with
- PEK stain with rose bengal slightly elevated, if microerosions occur with opacities NaFl stining occurs
- treatment of thygeson's disease
- weak topical steroids (pred Mild, alrex, FML QID for 3-4 days then quickly tapered); bandage CL and pressure patch ; if pt is contact lens wearer then discontinue CL wear
- what is non-herpetic interstitial keratitis
- vascularization and infiltration affecting all or part of the corneal stroma
- what is non-herpetic interstitial keratitis associated with
- systemic disease
- major sign seen with non herpetic interstitial keratitis
- ghost vessels from previous processes of active inflammatory vascularization are common. They appear as grayish lines or small tubes
- most cases of non-herpetic interstitial keratitis is secondary to what
- 90% of all cases are secondary to congenital or acquired syphillis -- an immunologic reaction to spirochete
- is non-herpetic interstitial keratitis associated with congenital syphilis unilateral or bilateral
- bilateral
- what age does congenital non-herpetic interstitial keratitis affect
- age 5 to late teens
- is acquired non-herpetic IK bilateral or unilaterla
- unilateral
- which is usually a mild case of non-herpetic IK
- aquired syphilis usually casues a mild and easier to treat conditionof non herpetic interstial keratitis
- what is the other cause of non-herpetic IK other than syphillis
- Tuberculosis makes up the majority of non-syphilitic cases -- it is an autoimmune reaction to tuberculin protein
- s/s of non herpetic IK in syphillitic cases
- during acute phase show infiltration, edema of endothelium, KP's, miosis, and small stromal opacities; most cases will be residual effects --diffuse stromal scarring, opacification, ghost vessels
- s/s of non herpetic IK in TB
- cornea is typically involved in peripheral inferior sector only and is ring-shaped
- Treatmento f non-herpetic interstitial keratitis
- keratoplasty if vision is impaired, in active IK steroids suppress inflammation and may be necessary for 1 to 2 years ; also cycloplege; id and treat systemic infection
- what is ocular cicatricial pemphigoid
- a chronic autoimmune disease characterized by scarring of the mucous membranes (conjuctiva, soft palate, nasal mucosa, genito-urinary system esophagus,etc.) and skin
- what is the average age of onset for ocular cicatricial pemphigoid
- 65 years old and females get it more than males
- what is the initial sign of ocular cicatricial pemphigoid
- chronic recurrent unilateral conjunctivitis
- stage 1 of ocular cicatricial pemphigoid
- subepithelial fibrosis
- stage 2 of ocular cicatricial pemphigoid
- fornix foreshortening
- stage 3 of ocular cicatricial pemphigoid
- symblepharon: adhesion of palpebral and bulbar conunctivia
- stage 4 of ocular cicatricial pemphigoid
- ankyloblepharon and surface keratinization: eyelid skin attaches to conjunctiva
- what is a late finding in the disease process of ocular cicatricial pemphigoid
- dry eye syndrome
- why is vision lost in ocular cicatricial pemphigoid
- vision is lost due to keratopathy, corneal neovascularization, and corneal ulceration and scarring
- what is the histopathology of ocular cicatricial pemphigoid
- submucosal scarring, chronic inflammation, perivasculitis, ans squamous metaplasia of the epithelium, with loss of goblet cells
- what does natural history of ocular cicatricial pemphigoid show
- periods of exacerbationand remission, sometimes quite profound
- what does a firm diagnosis require for ocular cicatricial pemphigoid
- immunohistochemical confirmation prior to initiating treatment
- CP dry eye is treated with what?
- non-preserved artificial tear dorps and ungs
- what is used for CP blepharitis and meibomianitis
- this is treated aggressively with lid hygiene, oral doxycline, topical antibiotics as necessary
- CP treatment
- topical retinoid ung (vitamin A) if benefit after monocular trial
- CP treatment for cases that are active and rapidly progressive
- prednisone 1 mg/kg/day, eventually tapered over a period of 8-16 weeks; cyclophosphamide 2 mg/kg/day, adjusted based on response
- CP treatment for cases that are not rapidly progressive and less active
- prednisone 1mg/kg/day, tapering as responds; dapsone 1mg/kg/day, not exceeding 200 mg/day
- CP treatment if all esle fails
- methotrexate; azathioprine
- why should the patient with CP be managed by someone who is experienced in this area
- to check for drug toxicity and tolerance
- another name for Steven Johnson Syndrome is what?
- erythema multiform
- etiology of steven johnson
- S-J syndrome occurs idiosyndratically in some patients, and is seen as mucosal inflammation in response to the administration of various drugs or following systemic infectious disease
- what can steven johnson syndrome appear similar to
- a disease that can appear clinically similar to ocular cicatricial pemphingoid, but is not the relentless, progressive disease that OCP is.
- s/s of acute phase of steven johnson
- the patient may appear to have a severe pseudomembranous conjunctiva; following resolution fibrosis of the conjunctiva with associated entropion and trichiasis may be present
- steven johnson is associatied with what other disease
- patients who develop S-J syndrome may have a predisposition to autoimmune disease
- treatment of S-J
- treat aggressively with topical anti-inflammatory agents
- common associationed diseases with S-J
- ocular rosacea, psoriasis, connective tissue disease
- ocular rosacea S-J s/s
- general increase in lipid secretions; hyperemia of lid margins, FBS, BURNING, recurrent chalazia
- treatment of ocular rosacea S-J
- oral doxycycline 100 mg BID first day, then 50-100 mg QD thereafter for 21 days; Or Tetracycline 250 mg QID; or retinoic acid
- psoriasis S-J affects which age group mostly
- 28 yrs old
- psoriasis S-J s/s
- hyperproliferation of keratinocytes in the epidermis. conjunctiva usually shows non-specific inflammation, chronic in nature and is associated with eyelid margin involvement; bleph can take the form of redness, edema, and skin plaques
- why is psoriasis S-J confused with phlyctenules
- the plaques seen in this disorder can extend onto the conjunctiva and cause scarring which can be confused with phylctenulosis
- treatment of psoriasis S-J
- supportive in conjunctiva with systemic treatment for psoriasis
- connective tissue disease S-J etiology
- usually thought to have and autoimmune etiology
- what are the different connective tissue diseases
- systemic lupus erythematosis, polyarteritis nodosa, relapsing polychondritis, reiter's syndrome and others(rheumatoid arthritis, scleroderma, dermatomyositis, rheumatic fever, thrombotic thrombocytopenic purpura (non specific conjunctival findings treat supportively)
- systemic lupus erythematosis s/s
- 3rd -4th decade females more than males butterfly rash on face, non-specific conjunctiva (hyperemia, fine papillae)
- systemic lupus erythematosis treatment
- treat conjunctiva supportively, systemic treatment is with aspirin, chloroquine, steroids
- polyarteritis nodosa s/s
- arteritis of small and medium vessels from severe hypersensitivity; many systemic findingw with non-specific conjunctivitis (may see subconjunctival hemorrhages) males greater than females
- polyarteritis nodosa treatment
- treat supportively systemic condition with steroids
- relapsing polychondritis s/s
- recurrent inflammation of cartilage seen in 3rd-6th decades. Females equal to males. mild conjuctivitis, more often episcleritis.
- relapsing polychondritis treatment
- treat supportively, systemic with steroids
- reiter's syndrome s/s
- triad of nongonococcal conjunctivitis, urethritis, arthritis. May be associated with chlamydia infection 90% of patients are male. Mild nonspecific conjunctival findings
- treatment of reiter's syndrome
- oral tetracycline, steroids for systemic findings
- treatment for non-specific conjunctival findings
- treat supportively
- which problem causes for a laboratory analysis to reach appropriate diagnosis and appropriate management plan
- infectious conjunctivitis or keratitis
- what does bacteriology use
- gram stain
- how can same day analysis be done
- using gram stain of any discharge or purulent material present.
- same day analysis is enough information for what
- to select appropriate initial treatment based on whether the organism is gram positive or negative or possibly fungal
- why is a culture done
- if there is only scant discharge available at the time of examination and a gram stain would be non-productive or is inconclusive.
- how is the culture done
- This procedure is analogus to the throat culture in that the conjunctival lid margin or corneal tissues are swabbed or scraped and then the mateial is inoculated ont a petri dish or into a curture broth. 24-48 hrs later the bacteria grown are gram-stained
- why do a sensitivity test
- to see how effective a cetain antibiotic is for your specific patient's bug
- how is the sensitivity test done
- the organism isolated from your patient's culture is grown onto a petri dish surface then several antibiotic laden paper disc are placed onto the grown bacteria. After reincubation the antibiotic with the largest kill zone surrounding it is presumably the most effective antibiotic for your specific patient's bugs
- why are cytology studies done
- to analyze the patient's cellular response to the infection or inflammation.
- what is cytology not a study of
- it is not an analysis of the organism responsible for the condition
- how is cytology done
- cells are removed by various different means and then analyzed microscopically. Based on the patient's cellular response you can reasonably predict what category of disease you are dealing with
- PMN's predicts what
- bacterial infections
- Lymphocytes predicts what
- viral infections
- Eosinophils and Basophils are predominant in what type of disorder
- allergic disorders