Professional Documents
Culture Documents
Books
1. Grayson’s Diseases of the Cornea
2. The Wills Eye Manual
3. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology
4. Heiberger, Madonna, and Nehmad Emergency Care in the Optometric Setting
5. Fraunfelder and Roy: Current Ocular Therapy
Atlases
1. Spalton: Atlas of Clinical Ophthalmology
2. Kratchmer: Cornea Atlas
Slide Sets
1. Spalton
2. Kratchmer-also in CD-ROM
3. Catania
Guides
1. Review of Optometry’s 2007 Clinical Guide to Ophthalmic Drugs
PATHOLOGY OF VIRAL DISEASE
1. Double-stranded DNA virus with numerous serotypes (diff. serotypes give diff. signs and symptoms)
2. Cause of a number of diseases: ocular, respiratory, GI, GU, urinary
3. Pathology *with any adenovirus, RTC 1 wk no sooner
o Disrupts host cell DNA synthesis and directly toxic to host * has some latency
o Causes cell lysis and virus release responsible for signs and symptoms
* Dx of an adenovirus was previously clinical, now can use a Rapid Pathogen Screening devise
Pharnygoconjunctival Fever
1. Adenoviral conjunctivitis with systemic signs (soar throat) and mild, transient corneal findings
2. Children: pharyngitis, follicular conjunctivitis, fever with submaxillary adenopathy
3. Supportive treatment
HSV HZV
Spread by direct contact or contaminated secretion Spread by aerosolization or direct contact w/ lesions
Milder disease as compared to HZV More severe disease as compared to HSV
More frequent reactivation as compared to HZV Infrequent reactivation
Latency in non-replicating cells Latency in non-replicating and replicating cells
Reactivation associated with trigger factors No obvious trigger factors
1. Pathology
o 90% of humans infected by age 15 (1st infection usually subclinical)
o Virus latent in trigeminal and superior cervical ganglia
o Reactivation triggered by factors such as stress, heat, fever, UV, trauma, hormonal changes, and
other less well-known factors; genetic predisposition
o Recurrent infection is diverse- virus enters latent phase in trigeminal and sup. cervical ganglia
2. Primary Infection
o Children (usually less than 5yo) *sx 2-12 days after contact
o Eye signs mild as compared to systemic (eye not usually 1* site of infection)
o Lid vesicles, ulcerative bleph, follicular conjunctivitis, +/- cornea (corneal changes superficial)
o Differential: adenovirus, chickenpox, Molluscum, Staph, vaccinia, Chlamydia
o Management: eliminate virus from cornea and adjacent structures with anti-viral (Trifluridine 5x/day
3. Recurrent Infection
o Latent virus activated
o Cornea primary site of disease in 1st ocular recurrence (other recurrences can go further back)
Epi: SPK, dendrites, geographic and amoeboid ulcers (dendridic ulcers is usually recurrent)
Metaherpetic disease in V1
Stromal disease: necrotizing and non-necrotizing *all of these produce
Endothelial disease massive discomfort
o May also affect TM, uvea
o If have a HSV, there is always a potential of getting an ocular breakout, but there is a genetic
component involved in the likelihood of the breakout
1. Clinical Picture
o Unilateral, follicular conjunctivitis. Ipsilateral lymphadenopathy. Discomfort and variable amounts
of pain (1st have pain, then as have recurrences, nerve cells get damaged and pain sensation dec.)
2. Cornea
o Dendrite is classic, but not always the presentation * may be central or peripheral
A true ulcer (loss of epi): base stains brightly with fluorescein, edges with rose
True terminal end bulbs (heaping up of tissue at ends)
o May present as SPK or large amoeboid or geographic ulcers (more severe in immunocompromised
or steroid fed)
o Will lead to corneal scarring, especially with recurrences: ground glass appearance – as get deeper
into tissue, can scar and appear as a whitish haze in the cornea
3. Treatment
o Although epithelial disease is self-limiting, treatment is indicated to reduce corneal damage and
reduce immune response to infection (on average dendrites heal in 6 days)
o 1% trifluridine sol. Q2h for first few days, taper as dendrites regress; no more than 9x/day (toxic)
o Supplement with tears and cycloplege for comfort
o No need for ointment at bedtime (Vira-A no longer available anyway)
o Debridement useful, particularly if large amounts of dead tissue
o NO TOPICAL STEROIDS IN ISOLATED HSV EPITHELIAL KERATITIS – since epi. keratitis is
infectious, the steroid feeds it.
o Oral agents are useful but not the current standard in U.S.; use when trifluridine toxic, when
epithelium in very bad shape, or in immunocompromised
o One week treatment with orals: Acyclovir 400 mg five times per day or Valacyclovir 500
mg three times per day or Famciclovir 250 mg three times per day
4. Recurrence
o 25% recurrence risk over two years after first episode of epithelial keratitis
o 43% risk after second recurrence
o Greater number of recurrences lead to: scarring and vascularization, increased risk of recurrence,
increased risk of stromal disease
o Even though disease is self limiting, tx dec. risk of damage and recurrence
o Complications Neurotrophic ulcer and SPK due to antiviral med. toxicity
Neurotropic Keratitis
(Metaherpetic Ulcer)
1. Epithelial defect due to loss of corneal innervation, BM damage and poor tear film (ie: stroke of CN V…)
2. Red eye, FBS, swollen lid - but not infectious
3. Range from SPK to full-blown ulcer – typically round or oval, not dendridic
4. BEWARE of secondary bacterial infection
5. De-epithelialization – need CN V to maintain connections b/w epi and BM so very easy to rub off epi
6. Treatment
o Mild: tears, erythromycin ung, bandage CL or patch
o Increasing Severity: treat as bacterial ulcer; consider tarsorraphy (sew lids together)
1. Inflammatory reaction to viral antigens. Not an active replication–may occur during or w/o epi disease
2. Inflammation deeper within the eye: stroma, endothelium, TM, uvea involved
3. Usually occurs after previous bouts of epithelial disease, but NOT always.
4. Clinical Presentation
o Uncomfortable eye (variable pain) with degreased vision
o Terminology variable
o Non-necrotizing and necrotizing
non-necrotizing interstitial keratitis – stromal inflammation w/ intact epithelium. Non-
necrotizing is often in the form of disciform keratitis (disk of edema with intact epithelium
and increased IOP)
necrotizing usually involves neovascularization
o Also: interstitial keratitis, keratouveitis, iridocyclitis
5. Treatment
o Aggressive inflammation management with antiviral cover: frequent use of steroid with slow taper +
Viroptic QID and taper with steroid
4 days QID
Steroids can activate HSV (trigger replication) so do not use steroids 3 days TID
for an active HSV infection (eipithelial) but for a stromal HSV (not 2 days BID
actively replicating) use a steroid Q2H and cover with an antiviral QID 1 day QD
o Manage IOP
o Cycloplegia for comfort
6. Recurrence
o 11%/year risk of developing stromal keratitis with or without treatment following epithelial keratitis
o HEDS II tells us that we can reduce the risk of recurrence of herpetic disease with long-term use of
oral acyclovir - 400mg Acyclovir BID for 1 year decreases the recurrence rate of any HSV by 30 and
stromal disease by 50% in those at risk for stromal disease
o Recommendation: use long-term acyclovir (or other oral) in patients at greatest risk of recurrence or
vision loss (does not treat, only decreases recurrence)
1. 1st division of trigeminal nerve and its brances (even if eye itself is not involved)
Ophthalmic and frontal most common
50% develop ocular complications: if tip of the nose involved Hutchinson’s sign (nasocilliary n.)
there is a 76% risk of ocular involvement vs. 34% if sign is missing
2. Widespread and diverse ocular signs – remember that direct occurs due to direct viral invasion, secondary
inflammation, vasculitis, nerve damage, and scarring
3. Clinical manifestations
o Lids: pitting, pigmentation, exposure, ectropion, entropion, dermal scarring (looks like a burn scar)
o Conjunctiva: follicular conjunctivitis, symblepharon and associated problems
o Cornea
• Early: SPK, SEI, keratouveitis, pseudodendrites (swollen epi that stains poorly, not a true ulcer)
• Delayed: serpiginous ulcers, mucous plaques, disciform keratitis
• Chronic: bullous keratopathy, neurotrophic keratopathy (round/oval, stains)
o Episcleritis and scleritis
o Uveitis, usually associated with corneal involvement -HSV usually
o Elevated IOP: trabeculitis, uveitic, synechia involves
cornea/stroma.
-HZV has the
potential to involve
the entire eye
o Neuro-ophthalmic: tonic pupil, optic neuropathy, ophthalmoplegia
o Retina: vascular occlusion, retinitis, choroiditis, ARN, PORN
4. Neuralgia
o Acute: with rash
o Postherpetic Neuralgia: persistant pain that can be severe
o Immunocompromised have a 3-4x higher risk of neuralgia
5. Treatment
o Treat skin with wet dressings
o Systemic: best if utilized within 72 hours of onset to reduce pain and decrease severity of post-
herpetic neuralgia (dec. duration and severity)
Acyclovir 800 mg five times/day x 7-10 days
Use one of the
Valacyclovir 1000 mg TID x 7 days three, not all
Famciclovir 500 mg TID x 7 days
o Ocular
Surface disease: tears and antibiotic
Deeper: steroids, cycloplegia, antibiotic coverage
Neurotrophic: as HSV
Scleritis: in consultation, treatment usually systemic
o Neuralgia
Acute: use antiviral to decrease severity and duration and analgesic
Post-herpetic: creams, H-2 blockers, TCA, ganglionblock (cut nerve)
CHLAMYDIAL INFECTION
Trachoma
1. Overview
o Leading cause of preventable blindness worldwide (poor, arid regions)
o Repeated reinfection by Chlamydia trachomatis – especially in kids (peak prevalence in 3-6yo)
o Transmission: ocular secretions hand to eye
o Possible role of flies, bacterial conjunctivitis, HLA type
2. Clinical Features
o Limbal follicles (Herbert’s Pits) and Follicular conjunctivitis (in kids the follicular conjunctivitis is
greater at the lower lid and in adults in the upper lid)
o Papillary reaction that may be significant
o Repeated infection leads to scarring: lids, conjunctiva (Arlt’s Line – horizontal line on upper
palpebral conj), cornea: entropion, trichiasis, corneal opacification
o Chronic follicular conjunctivitis scarring of conjunctiva lid and lash distortion (entropion and
trichiasis) corneal abrasion scarring of cornea blindness
o Usually a clinical diagnosis (no diagnostic tests)
4. Treatment
o World Health Organization SAFE strategy (Surgery for trichiasis, Antibiotics, Face washing,
Environmental improvements)
o Antibiotics
Tetracycline ung
Zithromax (azithromycin) 20 mg/kg in kids or 1 g in adults single dose
o Handwashing: shown to be the single best way to reduce incidence
1. Overview
o STD: C. trachomatis (same bug that causes Trachoma)
o Oculogenital disorder: about 1% of infected develop AIC but 54% of men and 74% of women with
AIC have a positive genital culture YOU HAVE A PUBLIC HEALTH ROLE
o Transmission is finger-eye
2. Clinical Features
o Inferior follicular conjunctivitis
o Non-tender node (preauricular)
o Lids stuck upon awakening
o Heals without scarring (self limiting)
o Chronic: common cause of chronic conjunctivitis
3. Diagnosis
o Conjunctival scrapings, Culture, ELISA, PCR
4. Treatment is SYSTEMIC
o Tetracyclines: tetracycline 250 mg x 21 days or doxycycline 100 mg BID x 21 days or azithromycin
1 g single dose
o MUST TREAT SEXUAL PARTNERS
1. Overview
o 1.6 – 12% of newborns
o Chlamydia more common than gonorrhea in industrialized nations
o Acquired from mother during delivery
o Associated with nasopharyngeal infection, other
2. Clinical Features
o About 5th day after birth
o Lid edema, conjunctival hyperemia, papillary hypertrophy (why no follicles?), mucopurulent
discharge, corneal infiltrates, can lead to scarring
3. Diagnosis
o MUST R/O N. gonorrhea
o Rule out other possible causes
o Crede’s prophylaxis also cause of conjunctivitis
4. Treatment
o Prophylactic erythromycin to babies born to infected mothers
Thygeson’s SPK
1. Possible viral etiology
2. Chronic condition with exacerbations and remissions
3. Uncomfortable eye during exacerbations
4. “White eye” (actually a little red) with bilateral, intraepithelial punctate opacities that stain
5. Treatment: tears, ung, mild steroid, mast cell stabilizers, bandage CL, antivirals, cyclosporine have been
utilized
Molluscum contagiosum