Antibiotic use for ocular conditions

internal hordeolum

What condition does this patient most likely have?

active infection of meibomian gland

What is an internal hordeolum?

localized redness and swelling, soft and warm to touch, quiet eye and lid margin

What are presentations of internal hordeolum?

external hordeolum

What condition does this patient most likely have?

active infection of gland of zeiss/moll

What is an external hordeolum?

protrusion (puss point) at the lid margin

What presentation differentiates an external hordeolum from an internal?

preseptal cellulitis

What condition shown here must we consider with a hordeolum?

diffuse redness that extends from canthus to canthus (entire lid)

What presentation differentiates a preseptal cellulitis from an internal hordeolum?

chalazion

What condition shown here must we consider with a hordeolum?

localized bumb of coagulated lipid within meibomian gland (NOT an active infection)

What is a chalazion?

hard nodule, NOT warm to touch, NOT red

What presentation differentiates a chalazion from an internal hordeoolum?

No predilection for age or gender

What is the epidemiology for an internal hordeolum?

acute and can be recurrent if associated with blepharitis

What is the temporal pattern for an internal hordeolum?

unilateral, swollen eyelid with localized redness and edema within a MG that is soft and warm to touch

What is the syndrome statement for an internal hordeolum?

systemically

Do we treat a worsening internal hordeolum topically and/or systemically?

Augmentin 500 mg tablets

What penicillin is the DOC for an internal hordeolum?

BID for 10 days

How often do we Rx Augmentin 500 mg for a patient > 88 lbs (40 kg)?

TID for 10 days

How often do we Rx Augmentin 500 mg for a standard adult patient > 115 lbs?

ability to swallow a pill? weight?

What should we ask our pediatric patients when Rx'ing Augmentin?

beta lactamase inhibitor

What is the MOA of clavulanic acid to help amoxicillin with staph protection?

cefprozil or Keflex (cephalexin) 500 mg BID for 10 days

What cephalosporin are DOC for an internal hordeolum in adults?

cefprozil 250 mg BID for 10 days

What cephalosporin is DOC for an internal hordeolum in kids?

Bactrim DS 800/160 mg BID for 10 days

What is the backup medication for infectious lid disease in adult patients with PCN or Ceph allergy?

azithromycin 500 mg QD for 3 days

What is the backup medication for infectious lid disease in pediatric patients with PCN or Ceph allergy?

stays at MIC due to slow metabolism and long half-life

Why can we Rx azithromycin for 3 days only?

bad GI effects (can be worse than eye problem)

Why do we not use Bactrim DS for pediatric patients?

azithromycin has a lot of staph resistance

Why do we NOT use azithromycin instead of Bactrim DS for adult patients?

diarrhea (warn patient and advise to stay hydrated)

What is the main GI effect from Bactrim DS?

MRSA of skin around eye

What is Bactrim DS DOC for?

MRSA of ocular surface

What is Polytrim DOC for?

do not try to express!!

warm compress to increase blood flow and more abx to target site (some palliative care)

What are other management plans for an internal hordeolum patient?

No

Is a follow up required for an internal hordeolum or bacterial conjunctivitis?

if they get worse or not healed by end of abx therapy

When can you tell a patient with an internal hordeolum or bacterial conjunctivitis to return to clinic?

may take a couple days to improve, but if completely resolved within 10 days still ALWAYS finish course of treatment (scare them by saying secondary infection will be worse)

What do we need to educate patients on that are taking an oral abx?

blepharitis

What ocular condition is shown here?

keratitis and uveitis

What ocular conditions are we concerned when a patient complains of photophobia (light sensitivity)?

multiple, peripheral corneal infiltrates with localized paralimbal injection

How would you describe what we see on slit lamp here?

ulcer

What does this staining pattern over the corneal infiltrates indicate?

infiltrates (erode the epithelium to create an ulcer)

Do infiltrates or ulcers come first?

marginal keratitis

What is most likely the diagnosis of the patient shown here? (not a CL wearer)

staph hypersensitivity reaction (inflammatory) due to poor lid hygiene

What is the cause of marginal keratitis?

exotoxins (from staph) deposit on cornea where the lid margin intersects

What causes corneal infiltrates (collection of WBCs) in marginal keratitis?

single lesion

What # of corneal lesions are more likely to be infectious?

central 6 mm

What location of a corneal lesion are more likely to be infectious?

entire lesion stains

What degree/size of staining of a corneal lesion is more likely to be infectious?

severe

What pain level is more likely to be infectious?

diffuse (360) injection

What pattern of redness is more likely to be infectious?

cells (look for hypopyon)

What AC reaction is more likely to be infectious?

culture

What is the only way to get a definitive diagnosis if a corneal lesion is infectious or sterile (inflammatory) in nature?

sensitivity

What other test is usually done with the culture to determine what antibiotic the bacteria is susceptible to?

1+ or greater AC cells

2 mm dense infiltrate

edge of infiltrate within 3 mm of central cornea (within pupillary zone)

What is the "1, 2, 3 rule" when predicting the likelihood of vision loss after resolution of infection? *Need to culture if ANY of the following exist

yes

Should we culture this lesion shown here?

yes

Should we culture this lesion shown here?

no

Should we culture this lesion shown here? *staining less than infiltrate size

adults

What is the epidemiology of marginal keratitis?

acute and recurrent with ongoing blepharitis

What is the temporal pattern of marginal keratitis?

typically unilateral red eye with mild to moderate symptoms of pain, tearing, irritation, and photophobia, exam reveals multiple corneal infiltrates or ulcers with minimal staining, localized conjuntival injection near lesion on limbus, no or minimal AC reaction, typically seen with staph blepharitis

What is the syndrome statement for marginal keratitis?

yes, topical (combo steroid/abx)

Does marginal keratitis warrant pharmaceutical treatment? If so, do we need to treat topically and/or systemically?

anti-inflammatory

What is the steroid component used for in marginal keratitis?

remove stimulus that caused bacterial colonization

What is the abx component used for in marginal keratitis?

Zylet ophthalmic suspension (0.3% tobramycin, 0.5% loteprednol)

What is our brand name DOC for marginal keratitis?

0.3% tobramycin/0.1% dexamethasone ophthalmic suspension

What generic is our DOC for marginal keratitis?

1 gtt q2hr for 2 days, then QID for 5 days

What is the dosing pattern for Zylet and generic Tobradex?

SHAKE WELL PRIOR TO USE

What do we have to remember to include on the Rx for Zylet and generic Tobradex?

daily lid hygiene

What are our other management plans for a patient with marginal keratitis?

OcuSoft Plus Lid Scrubs

What is a good soap-based lid hygiene product to recommend?

hypochlorous acid

What do medicinal-based lid hygiene products contain?

preservative free

What is a benefit of hypochlorous acid?

yes, due to corneal involvement

Do we need to follow up with a marginal keratitis patient?

emphasize compliance to drops and lid hygiene and check IOP due to steroid component

What are other benefits of following up with our marginal keratitis patient?

bacterial conjunctivitis

What ocular condition is most likely diagnosis shown here?

mucopurulent discharge

What is pathognomonic for bacterial conjunctivitis?

eyes stuck shut upon waking

What is the most common complaint from mucopurulent discharge?

Neutrophils (PMNs)

What white blood cells are found in mucopurulent discharge?

inferior conjunctiva

Where does redness most commonly occur in bacterial conjunctivitis?

papillae

What is a common finding on the inferior palpebral conj in bacterial conjunctivitis?

toxicity of PMNs

What may cause inferior corneal staining in bacterial conjunctivitis?

adult inclusion conjunctivitis

What ocular condition can have ongoing mucopurulent discharge and is secondary to chlamydia?

follicles on superior palpebral conj

What is pathognomonic for adult inclusion conjunctivitis?

EKC

What viral ocular condition can have a "mucopurlent discharge" with other symptoms such as profuse watering, chemosis, and lid edema?

pseudomembrane

What mimics mucopurulent discharge in EKC?

hyperacute conjunctivitis (onset of 6 hours)

What do we always need to rule out in a bacterial conjunctivitis, as shown here?

neisseria gonorrhoeae

What is the #1 cause of hyperacute conjunctivitis?

can penetrate an intact epithelium and perforate the globe

Why is hyperacute conjunctivitis a medical emergency?

true purulent (snow white)

What type of discharge does hyperacute conjunctivitis have?

1g IM Ceftriaxone (3rd gen ceph) and 1g azithromycin

What is the systemic treatment for hyperacute conjunctivitis?

Ciloxan (ciprofloxacin) q1-2 hrs and irrigation q1hr to clean out discharge

What is the topical treatment for hyperacute conjunctivitis?

No predilection for gender or age

What is the epidemiology for bacterial conjunctivitis?

acute

What is the temporal pattern for bacterial conjunctivitis?

burning

What is the most common symptom of bacterial conjunctivitis?

complaints of burning, FB sensation, lids stuck shut in the morning due to mucopurulent discharge, signs of meaty redness that is worse in inferior bulbar conj and papillae in inferior palpebral conj

What is the syndrome statement for bacterial conjunctivitis?

gradient of redness

What do we call the transition of white eye to red eye in bacterial conjunctivitis?

yes, topical antibiotic only

Does bacterial conjunctivitis warrant pharmaceutical treatment? If so, do we need to treat topically and/or systemically?

assist immune system to lower bacterial count and get better faster

Why would we treat a bacterial conjunctivitis patient and how do antibiotics do this?

3-5 days

When does our peak immune response occur after infection?

after 24 hours on drops

When are bacterial conjunctivitis patients no longer contagious if being treated?

after discharge resolves

When are bacterial conjunctivitis patients no longer contagious if not being treated?

tobramycin 0.3% ophthalmic solution

What is our topical DOC for bacterial conjunctivitis due to dosing schedule?

1 gtt QID for 7 days

What is the SIG for tobramycin in treatment of bacterial conjunctivitis?

tobramycin and gentamycin

What topical antibiotics are available as ung for bacterial conjunctivitis in kids?