Ant Seg 2 L6: Inflammatory Conditions of the Cornea

What is the definition of interstitial keratitis?

Any non ulcerating inflammation of the corneal stroma without the involvement of the epitheliuma and endothelium

What are causes of interstitial keratitis?

Syphilis, HSV, HZV, TB

What bacterial causes syphilis?

Treponema pallidum

What is nicknamed the greatest imitator and mimicker?

Syphilis

What is the shape and gram status of T. Pallidum?

Gram negative spiral shaped

What is the most common stage of syphilis?

Congenital

What characterizes the primary stage of syphilis?

Chancre

What characterizes the second stage of syphilis?

Skin or mucous membrane lesions

Fevers, myalgias, HA, anorexia, sore throat, weight loss, joint pain, malaise, cutaneous manifestations

What characterizes the latent stage of syphilis?

No manifestations lasting months to 30 years

What are the ocular manifestations in the primary stage of syphilis?

Chancre on eyelid

What are the ocular manifestations in the secondary stage of syphilis?

Uveitis, optic neuritis, active chorioretinitis, vasculitis, episcleritis/scleritis, keratitis

What are the ocular manifestations in the tertiary stage of syphilis?

Optic atrophy, old chorioretinitis, interstitial keratitis, argyl Robertson pupil with secondary stage

what is the most common cause of interstitial keratitis?

Congenital syphilis

80% of cases of congenital interstitial keratitis are ________

Bilateral

Hutchinson teeth and hypopigmented skin lesions are caused by what?

Congenital syphilis

What are the signs and symptoms of syphilitic interstitial keratitis?

Corneal and stromal edema, neo, KPs, injection, Blur/pain/photophobia

If you are suspicious for HSV and VZV, also test for what?

Syphilis

What is the lab work for syphilis?

FTA-ABS

Treponemal assay

VDRL

RPR

What is the lab work for HSV and VZV

PCR and swab testing

What is the lab work for TB?

Quantiferon gold, PPD, chest x ray

What is the pharmacological treatment for acute corneal interstitial keratitis?

Prednisolone acetate 1% 1gtt QID to q2 depending on severity

Must monitor IOP

Cyclopentalate 1% 1gtt BID for pain

What is the Tx for old inactive disease or scarring? (Corneal interstitial keratitis)

Corneal transplant (PK)

How is neuro syphilis treated?

Aqueous crystalline penicillin G IV 10-14 days

Follow with IM penicillin weekly for 3 weeks

What is the follow up for interstitial keratitis?

Every 5-7 days

What are filaments in filamentary keratitis?

Complex of epithelial cells, mucus, and inflammatory cells

What causes filamentary keratitis?

Mechanical friction from the palpebral surface

What is the Tx of filamentary keratitis?

Treat underlying condition

Debridement of filaments

Lubrication and DES treatment (PF ATS 6-8x per day, xiidra/restasis BID)

Acetylcysteine 10% 1gtt QID

Bandage CL with 4th gen FQ QID

What is the follow up for filamentary keratitis?

1-4 weeks depending on severity

May need combo of therapies for treatment

What is SPK of thygeson?

Coarse punctuate gray lesions with little or no conjunctival hyperemia

Lesions are concentrated in the central to paracentral cornea and are entirely epithelial

What are the signs and symptoms of SPK?

Photophobia, burning, tearing, and blurred vision

Patients often have long Hx of spontaneous exacerbation and remission

Lesions appear as fine granular white to gray dot like opacities

What is the Tx for SPKT?

Corticosteroids: loteprednol 0.5% 1gtt QID with a slow taper

DED therapy maintenance: cyclosporine 0.05% BID, ATs TID-QID

What is the follow up for SPKT?

Initially 5-7 days

Then every 3 weeks to 6 months

What is neurotrophic keratitis (NK)?

Degenerative disease of corneal epithelium characterized by impaired healing

What is the hallmark sign of NK?

Reduced corneal sensitivity

Ends up with corneal melting in severe cases

What conditions can cause NK?

HSV, VZV, Post lasik/PRK, topical anesthetic abuse/chemical injury, chronic CL wear

What is the role of corneal nerves?

Sensation, tear production, blinking, integrity, and immune regulation

All crucial for ocular surface health

What are the branches of the trigeminal nerve?

ophthalmic, maxillary, mandibular

How do you test corneal sensitivity?

Cotton wisp

What are clinical signs and symptoms of NK?

Foggy and blurry vision, redness, FB sensation, loss of corneal sensation, EPI defects, ulceration

What are the traditional dry eye treatments for NK?

Cyclosporine (restasis 0.05% BID) - calcineurin inhibitor that blocks T cells, stings

Lifitegrast (Xiidra 5% BID) - integrin agonist, blocks LFA1 x ICAM1, stings, metallic taste

What can you apply to cornea for NK?

Amniotic membrane

What recombinate nerve growth factor can be used in NK to regenerate nerves and epithelium?

Cenegermin 0.002% oph soln (Oxervate) 1gtt 6x daily for 2 mos - FU at 1 mo and 2 mos

What can you add to Tx of NK to prevent infx?

4th gen FQ (if true ulcer, must treat like bacterial keratitis)

What is band keratopathy characterized by?

Corneal plaque (calcium) at the level of bowman's membrane

Where does plaque occur in band keratopathy?

Begins at 3 and 9 position and can advance centrally

What are causes of band K?

Chronic uveitis, trauma, longstanding glaucoma, post retinal detachment, severe dry eye, idiopathic, hypercalcemia (less common)

What is the pathophysiology of band K?

Imbalance of calcium and phosphate metabolism resulting in deposition of Ca-phosphate crystals in supepithelial bowman's layer, epithelial basement membrane, and anterior stroma

What are the signs and symptoms of band K?

FBS/irritation, blurred vision

What is the treatment of mild band k?

Artificial tears QID

What is the treatment of moderate/severe band k?

Debridement with EDTA 3-4%

What is phlyctenular keratoconjunctivitis (PKC)?

Hypersensitivity reaction to a specific antigen most commonly TB or staph origin, characterized by phlyctenule (blister) on the cornea or conjunctiva

What is PKC often confused with?

Pterygium

What type of hypersensitivity reaction is PKC?

Type IV

What are the signs and symptoms of PKC?

Blister appearance, hyperemia, corneal NV and inflammation, pain, FBS, photophobia

What is the Tx of the inflammatory response of PKC?

Prednisolone 1% 4-6x daily with taper based on response (ie weekly)

Doxy 100mg QD PO in difficult cases

Eyelid hygiene

What is the Tx of corneal ulceration in PKC?

Same as bacterial keratitis (come back to this)

What is the FU of PKC?

Inflammatory only: weekly (monitor IOP)

Corneal involvement: 2-7 days

What is marginal staph keratitis?

A peripheral corneal disorder - inflammatory infiltration that may lead to ulceration

T/F - marginal staph keratitis is thought to be an AB reposnse rather than a direct baterial invasion

True

What is the most common peripheral corneal disorder?

Marginal staph keratitis (MSK)

What type hypersensitivity reaction is MSK?

Type III - bacterial antigen trigger peripheral immune response

What is the classic location of MSK?

1-2 mm central to limbus

What are the signs and symptoms of MSK?

Pain, photophobia, peripheral corneal infiltrates at 2, 4, 8, 9 where lid margin crosses limbus

What is the treatment of MSK without corneal involvement?

Loteprednol 1gtt 4-6 times daily

What is the treatment of MSK with stromal infiltrate and corneal breakdown?

Prednisolone 1% 1gtt QID

Broad spectrum antibiotic: 4th gen FQ 1gtt TID or polytrim 1gtt QID

What is peripheral ulcerative keratitis (PUK)?

Peripheral corneal thinning that might be associated with sterile infiltrate or ulceration

What could severe thinning in PUK lead to?

Perforation

What conditions may cause PUK?

Mainly Lupus (SLE) and rheumatoid arthritis (RA)

Full list: RA, Polyarteritis nodosa, IBD, collagen vascular disease (SLE), granulamatosis with polyangiitis, staph hypersensitivity, temporal arteritis

What is the pathophysiology of PUK?

Immune complex activates the complement system and recruits monocytes and neutrophils which release proteinases and collagenases that break down the corneal stroma in the periphery

What are the signs of PUK?

Crescent shaped stromal lesion, peripheral infiltration with overlying EPI defect

What are the symptoms of PUK?

Pain, redness, tearing, decreased va

What is the treatment of PUK?

Ophthalmic ointment: erythromycin ung q2h

Cyclopentalate 1% BID for pain

Prednisone 60-100mg QD PO

Immunosuppressants: methotrexate

Biologics: CD20 and TNF alpha inhibition

Graft if perforation pending

What is the FU for PUK?

Daily

What is Mooren ulcer?

IDIOPATHIC - Painful, progressive, chronic ulcerative keratitis that begins peripherally and progresses circumferentially and centrally

What is the pathophysiology of mooren ulcer?

Unknown, dx of exclusion

What are the signs and symptoms of mooren?

Crescent shaped peripheral lesion, peripheral infiltration with overlying epi defect

Pain, redness, decreased va

What is the treatment of mooren?

Comical corticosteroid: prednisolone 1% 1gtt q1h

Topical antibiotics: prophylactic use - besivance 0.6% 1gtt TID

Conjunctival resection

Local immunosuppression: topical cyclosporine and interferon A2b injection

Systemic inmunosupresión: oral pred, cyclophosphamide/methotrexate

Who do we refer PUK and mooren to and why?

Corneal specialist because of risk of corneal perforation