Disease - MT2

What are the Big 3 Diagnoses for Red/Pink Eyes

1. Acute Angle-Closure Glaucoma

2. Uvetitis

3. Conjunctivitis

What are signs/symptoms of Acute Angle-Closure Glaucoma?

Significant Pain

Pupil: Mid-dilated High IOP

Your patient has significant pain and the pupil is mid-dilated with a high IOP. What does this indicate?

Acute Angle-closure glaucoma

What are the signs/symptoms of Uveitis?

Photophobia

Pupil: Miotic, Anterior Chamber Cell

Is pupil size affected or unaffected by conjunctivitis?

Unaffected

Is anterior chamber affected or unaffected by conjunctivitis?

Unaffected

Is IOP affected or unaffected by conjunctivitis alone?

Unaffected

During a slit lamp assessment, ____ is most commonly unaffected by conjunctivitis

Cornea

A subconjunctival hermorrhage is associated with

Epidemic Keratoconjunctivitis (EKC)

What is Conjunctivitis

Inflammation of the conjunctiva (bulbar and palpebral) —> Eye appears red / pink

If the conjunctivitis is unilateral, what can the etiology be?

Adult bacterial

Herpes simplex keratitis

Herpes zoster ophthalmicus

Adenoviral at starts

If the conjunctivitis is bilateral, what is the most likely etiologies?

Ophthalmia neonatorum

Toxic

Allergy

Adenoviral infectious

What is TORCH complex (may result in conjunctivitis)

Toxoplasmosis
Others (Syphilis, Varicella Zoster Virus)

Rubella

Cytomegalovirus (CMV)
Herpes

At what age is H. flu most common

4 years old

What are the epidemic conditions for children?

Epidemic Keratoconjunctivitis (viral)

Pharynogoconjunctival fever

What is the most common causative bacterial organism in the US?

Staph Aureus

What are other frequent organisms (but less common than S. aureus)

Staph. epidermidis (Gram-positive)

Strep. pneumoniae

H. flu

What does Staph. epidermidis usually cause

Lid disease

What is Strep. pneumoniae (Gram - positive)

Respiratory spread
Often with URI history

What is H. flu (gram-negative)

Easily spread

Possibly accompanied by URI, ottis, media lymphadenopathy

What is conjunctivitis-otitis syndrome

H. influenzae conjunctivitis spreads easily in schools and households

Concurrent systemic findings of: URI and ottis media

What are are unusual organisms with conjunctivitis presentation?

Moraxella (Gram-negative)

E.coli (Gram-negative)

Proteus Species (Gram-negative)

What does Moraxella cause

Chronic conjunctivitis and angular blepharitis

Where is E.coli found?

Normal in lower GI tract
Possible in parents of diapered kids or caregivers

What is the mechanism of spread of conjunctivitis

Fomite spread

Epidemic spread (Among children)

Staphylococcal conjunctivitis

• May occur as an exacerbation of staphylococcal blepharitis and colonization of microbes in meibomian glands

E.coli possible when handling dirty diapers

Occult causes: Otitis media, pneumonia, and meningitis

What are Acute Bacterial conjunctivitis: Classic Signs

Hyperemi conjunctiva

• Beefy, engorged vessels

• Small and large caliber, irregular, and radiating

  • Rang of presentations from mild to very red

Strep. pneumoniae tends to be epidemic in the _____

Cold weather

(With concurrent URIs)

Hemophius tends to be epidemic in

Warm weather (Summer / Early Fall

What are Gram + bugs

Staph species

Strep species

What is a gram - bug

Neisseries
Enteric E coli

Moraxella

Haemophilius

Pseudomonas

What is a gram positive bug treatments

Neomycin
Erythromycin
Bacitracin

What is a gram negative bug treatment

Polymyxin B

Gentamycin

Tobramycin

How long is duraiton for treatment of Acute Bacterial Conjunctivitis?

7 days

What is the first choice of drops treatment for Staph. conjunctivitis

Topical fluoroquinolone (3rd/4th gen):

• Moxiflocin TID

What is first choice of ointment for treatment of staph. conjunctivitis?

Bacitracin ointment

• At least QHS (or QID for kids when using ointment only for Tx)

What is a good alternative to bacitracin

Erythromycin

(Although increasing resistance to Staph)

Trimethoprim

• Not bactericidal but decreased resistance even to MERSA with Polytrim

Why is Sulfacetamide NOT recommended to treat Acute Bacterial Conjunctivitis?

Significant resistance of Staph

Why is chloramphenicol, tetracycline, and neomycin not first choice treatment of Acute Bacterial Conjunctivitis?

Resistance of Staph

What are signs to suspect/suggest Streph for Acute Bacterial Conjunctivitis

Petechial sub-conjunctival hemorrhages

Epidemic/concurrent URI

What are the best choices of treatment for Acute Bacterial Conjunctivitis (Streph)

1. Fluoroquinolone drops (Moxifloxicin) TID/QID to q2-3H

2. Bacitracin ointment

3. Erythromycin ointment

4. Polytrim drops Q 2-3 H to QID

5. Sulfacetamide drops Q 2-3 H to QID

Why are chloraphenicol drops generally NOT used in the US

Risk for aplastic anemia

What are signs/symptoms of Hemophilius conjunctivitis

Organism suggested by florid presentation, heavy mucopurulence

What are the best choices of therapy for Hemophilius conjunctivitis?

Oral amoxicillin / clavulanate (Augmentin)

Why is sulfacetamide not used to treat Haemophilus

Neutralized by PABA in potentially heavy purulence

What are the adjunctive bacterial conjunctivitis adjunctive therapyies?

1. Frequent hand washing

2. Warm compresses if Lid (Cool compress if redness)

3. Artifical Tears (AT)

4. Careful hygiene and prevention of spread of infection

What are the careful considerations for Acute Bacterial Conjunctivitis

Never patch (Bacteria love dark, warm, damp environments)

Ointments often work better for young children

Reservoir technique with Rx or OTC

Don’t reuse medications after 6-8 weeks

What are the two causative organisms of Hyperacute Bacterial Infection

Neisseria gonorrhoeae - More common

Neisseria meningitidis - Less common

N. gonorrhoeae transfer during Neonate

In utero or during childbirth - through birth canal of infected mother

N. gonorrhoeae transfer during Adolescent

Fomite spread from infected adult

N. Gonorrhoeae transfer as an adult

Inoculation from infected genitalia

How can you prevent Ophthalmia Neonatorum?

1. Erythromycin 0.5% eye ointment

2. Tetraccycline hydrochloride 1% eye ointment

3. Povidone iodine 2.5% solution (water-based)
   
   

4. Silver Nitrate 1% solution or

   1. Chloramphenicol 1% eye ointment

How does N. Meningitidis spread?

From healthy carrier or person who has recovered from disease

Nasophrynx is a major portal and harbo4

Systemic Manifestation of Neisseriaceae

N. Gonorrhea: Urethritis, prostatis, epididymitis, pelvic inflammatory disease, vaginitis, cervicitis, proctitis

N. meningitids: Meningitis, septicemia, primary pneumonia

What are the urgent/emergent condiitons for Neisseria

1. Can penetrate intact corneal epithelium

2. Ulceration, perforation, endophthalmitis

What are the organisms capable of penetrating the intact epithlium: CHANNLS

C - Corynenacterium diphteriae

H - Haemophilus influenza

A - Acanthamoeba (Protozoan)

N - Neisseries gonorrhea

N - Neisseria meningitidis

L - Listeria species

S - Shigella

What are hyperacute bacterial conjunctivitis - Neisseria: Signs

Copious overflowing discharge

Usually bilateral by time of exam
Swollen pre-auricular nodes

What is the onset for Hyperacute Bacterial Conjunctivitis - Neisseria

Neonate 36-72 hours after birth

If gram stain shows gram (negative) intracellular diplococci suspicion of Gonococcal conjunctivitis, what should you do

Plating = Blood and Chocolate

Thayer - Martin culture recommend for Gonococcal conjunctivitis along with blood and chocolate

Serology = Nucleic Acid Amplication Test (NAAT)

Preferred over cultures —> Detects genetic material of pathogen

What are the treatment options for Gonococcal conjunctivitis (GC)

Ceftriaxone 50 mg/kg (max of 150 mg)

Kanamycin 25 mg/kg (max of 75 mg)

Spectinomycin 25 mg/kg (max of 75 mg)

What is Chronic Bacterial Conjunctivitis

Red eye and ocular irritation > 4 weeks duration

Often, vague, uncertain onset of conjunctivitis (weeks to months, not hours to days)

What is the ocular history of a patient with Chronic Bacterial Conjunctivitis

History of blepharitis and/or conjunctivitis treated without complete success

Possibly frequent hordeola and chalazia

Chronic Bacterial Conjunctivitis review of systems?

Pain on urination, rashes

What are the symptoms of Bacterial conjunctivtis

Matting of lids, worse, when waking up

Complaints of: Stinging, Burning, Irritation

• Associated: PEK

How does chronic bacterial conjunctivitis compare to acute conjunctivitis?

Hyperemia, chemosis, and discharge

• Minimal compared to acute conjunctivitis

What are common slit lamp findings for Chronic Bacterial Conjunctivitis

Slit Lamp Findings:

• Common: Lid inflammation / Chronic blepharitis (flakes, debris, red margin)

• Often due to Overgrowth of normal Bacterial flora

Pink/Red conjunctiva

Disrupted tear film
Punctate keratitis (PEK)

What is the most common eitology for Chronic Bacterial Conjunctivitis?

Staph. epidermidis or Staph. aueus

What are signs of Staphylococcal Blepharitis

Fibrinous sclaing (cornflake)

Ulcerative scaling (yellow, hard, bound down)

Lid ulceration
Marginal infiltrates

Punctate staining, inferior third of cornea

What are the signs of staphyloccal related Meibomian gland dysfunction

Significant impaction of secretion

Focal swelling of orifices —> Serration
Lids swollen and diffusely red

Signs of Hypersensitivity to Exotoxins

Marginal corneal infiltrates
Phlyctenule

What is the treatment of Chronic Bacterial Conjunctivitis

Complete eradication of Staph. is impossible

Goal: Kill enough microbes to allow lids and conjunctiva to function normally

Must be aggressive initially - Resistance to many antibiotics is likely

Control colonization

Chronic Conjunctivitis with lid involvement - Rx Medicaiton considerations

Azasite drops (topical azithromycin): BID x 2 days then 1 drop 1x/day (qhs) x 12 days combined with warm compresses

Combination AB/steroid (Tobradex ST) used QID for 2 weeks then lid hygiene techniques mentioned preivous

How long does chronic follicular conjunctivitis last for

>16-28 days

If mother is positive for Chlamydia, there is a ___ chance of developing neonatal inclusion conjunctivitis

50%

How is adult inclusion conjunctivitis often diagnosed

Non-responsive with traditional antibiotic treatment

Most viral eye infections are treated _____ rather than directly

Supportively

What is Adenovirus associated with

Upper Respiratory Infections (URI)

For Adenovirus, patients are generally highly contagious for ____ days after onset

10-12 days

What is the most frequent cause of Infectious conjunctivitis?

Adenoviral Conjunctivitis

The most common causes of acute conjunctivitis are related to the following serotypes:

3, 4, 8, 11, 19, 37

What serotypes are most responsible for Epidemic Keratoconjunctivitis (EKC)

8, 19 (Higher risk)
4, 37 (Less common)

What serotypes are most responsible for Pharyngeal-Conjunctival Fever (PCF)

2, 3 (Most common)

4, 5, 7

What serotype(s) is associated with Acute Hemorrhagic Conjunctivitis?

11

What serotypes are responsible for nonspecific follicular conjunctivitis?

1-11

19

Up to 65-90% of viral conjuncitivitis is related to ____

Adenovirus

What are differential diagnoses for Adeoviral Conjucntivitis

Herpes related follicular infections
Bacterial conjunctivitis
Allergic conjunctivitis

Symptoms of Simple Adenoviral Conjunctivitis

Acute onset of pink eye

Redness

Discharge (Thick and clear)

Sensitvity to light

Starts in one eye —> May spread to both eyes

What are the signs of Simpel Adenoviral Conjunctivitis

Follicles in lower fornix

Serous / thick tear discharge

Conjunctival chemosis

Conjunctival injection

Swollen, red eyelid possible

Pan Likely (but not 100%)

What disease is this

Simple Adenoviral Conjunctivitis

What is the management for Simple Adenoviral Conjunctivitis

Limit Spread of Infection:

Wash hands frequently
Don’t share bedding
DIscard cosmetics

Supportive (Pallative) Treatment:

• Artifical Tears (AT), vasoconstrictors, cool compresses, NSAIDs

• If secondary corneal invovlement, cover with prophylactic antibiotics

  • Polytrim

What are the off label treatments for Simple Adenoviral Conjunctivitis

Betadine Povidone-Iodine (PVI) regimen:

• 1 drop proparacaie + 2-3 drops Betadine 5% ophthalmic prep

Hypochlorous acid
Off label antiviral: Zirgan

Why is Zirgan used off=label for Adenoviral treatment

Shorts duration of the ocular disease HSV

What is the testing/assessment options for Adenovirus?

1. Conjunctival cytology studies

2. Viral Cultures

3. PCR

   1. RPS?Adenodector/QuickVUe Adenoviral conjunctivitis test

      1. Detects presences of adenovirus in the pt’s tears (Not differentiated and not for HSV)

AdenoPlus detects

All KNOWN serotypes of adenoviral conjunctivitis

What are the adenoviral types of presentations

1. Epidermic Keratoconjunctivitis (EKC)

2. Pharyngo-conjunctival fever (PCF)

3. Acute Hemorrhagic Conjunctivitis (Adenoviral possible)

What is Epidemic Keratoconjunctivtis (EKC)

HIGHLY contagious
More extreme signs and symptoms compared to simple adenoviral conjunctivitis

What the timelines of Epidemic Keratoconjunctivitis (EKC)

Rule of 8:

1. Day of 1-7: Incubation / Asymptomatic but infectious

2. Day of 8-16: Active Infection/Conjunctivitis (still infectious)

3. Day 16+: Corneal Involvement = Subepithelial infiltrates (SEIs) appear, no longer contagious

   1. Vision gets worse

   2. Pseudomembranes start to increase FBS symptoms

Less than 5% of the population has developed _____ against EKC. EKC is a disease of ___

Neutralizing antibodies

Re-infection and no immunity

Type ___ is implicated in iatrogenically caused epidemics (EKC)

8

Type ___ is more common among families and co-workers (EKC)

19