Mile Brujic, OD, FAAO · SPK/Ulcers Keratoconus Anterior polar cataracts Mucous discharge Atopic...
Transcript of Mile Brujic, OD, FAAO · SPK/Ulcers Keratoconus Anterior polar cataracts Mucous discharge Atopic...
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Mile Brujic, OD, FAAO
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I have received honoraria in the past 2 years for speaking, writing, participating in an advisory capacity or research from: ABB Optical, Akorn, Alcon Laboratories, Allergan, Art Optical, Bausch + Lomb Health, Contamac, CooperVision, Euclid, Eyevance, Johnson & Johnson Vision Care, Luneau, Oculus, Optovue, Shire, Sight Sciences, Sun Pharma, Tangible Science, TelScreen, TruForm Optics, Valley Contax, Visionary Optics, VMax Vision, Walman Optical, Weave, Zeiss and Zea Vision
Mile Brujic, OD, FAAO
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Gets reported to AOA What you need to do: Report contact lenses that are sold illegally Report contact lens complications It only takes a few minutes to report
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Non-Steroidal Anti-inflammatory Drug (NSAID)• Provides analgesic, antipyretic and anti-inflammatory
effects• Inhibits cyclooxygenase
• COX-1 and COX-2• COX-1 – normal physiological response (stomach)• COX-2 – facultatively expressed - inflammation
• COX produces prostaglandins and thromboxanes from arachidonic acid
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Non-Steroidal Anti-inflammatory Drug (NSAID)• May Slow or delay wound healing• Epithelial breakdown• Corneal thinning • Corneal erosion• Corneal ulceration• Corneal perforation
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Non-Steroidal Anti-inflammatory Drug (NSAID)• Bromfenac 0.075% (Bromsite – SunPharma)• Bromfenac 0.09% (Bromday), 0.07% (Prolensa) – both
are qd dosing regimen• Ketorolac Tromethamine 0.5% (Acular), 0.4% (Acular
LS), 0.45% (Acuvail – qd/pf)• Nepafenac 0.1% (Nevanac tid); 0.3% (Ilevro qd)
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• Steroids• Steroid receptors complex influence DNA transcription
in the nucleus of the cell• Inhibits transcription of COX-2, cytokines, cell adhesion
molecules• Inhibits edema, fibrin deposition, capillary dilation, and
phagocytic migration, and scar formation.
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Steroids affect this step
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Treatment Options
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Ointments
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• Steroids• Durezol• Preserved with sorbic acid• Provides drop to drop uniformity
60708090
100110120130140
Inverted, not shaken -DUREZOL(R) Emulsion
Upright, shaken -DUREZOL(R) Emulsion
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Omega - 3’s
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X
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Why Do Omega 3’s Work?
Eicosapentaenoic acid / Docosahexaenoic acid(EPA/DHA)
Prostaglandin - 3(Anti-inflammatory)
Cyclooxygenase
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IMPORTANT:
EPA/DHAFish Oil
>70%
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• Oral Pain Medications• Ibuprofen• Norco (formerly Vicodin)• Darvocet (recalled)• Tylenol 3• Tylenol 4
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• Analgesic• Pain killer or achieving relief from pain
• Antipyretic• Reduction of fever
• Anti-inflammatory• Reduction of inflammation
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Non-Steroidal Anti-inflammatory Drug (NSAID)
• Provides analgesic, antipyretic and anti-inflammatory effects
• Inhibits cyclooxygenase• COX-1 and COX-2• COX-1 – normal physiological response (stomach)• COX-2 – facultatively expressed - inflammation
• COX produces prostaglandins and thromboxanes from arachidonic acid
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• p.o. q6hrs prn• 200mg – OTC• 800mg – prescription
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Non-Steroidal Anti-inflammatory Drug (NSAID)
• Contraindicated in patients with known hypersensitivity
• Because of effects on COX, can have gastrointestinal effects on patient
• Rarely can cause autoimmune conditions (stevensjohnson syndrome)
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Non-Steroidal Anti-inflammatory Drug (NSAID)
• Vioxx (Refecoxib)• COX-2 inhibitor• Recalled in 2004• prescription
• Bextra (recalled)• Mobic (Meloxicam)
• 7.5 and 15mg tablets• Celebrex (Celecoxib)
• COX -2 inhibitor• prescription
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• 220 mg p.o. q8-12 hrs prn• OTC• 500 mg – prescription strength
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T-Cells are believed to be the cause of ocular surface inflammation
Commercially available as Restasis 0.05% concentrationPreservative free Single vialsMulti-dose bottlePatented non-preserved system that
maintains its sterility Is an immunosuppressive agent
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In patients whose tear production is presumed to be reduced due to ocular inflammation associated with keratoconjunctivitis sicca, cyclosporine emulsion is thought to act as a partial immunomodulatory
What is the future for cyclosporine Generic formulations may arise Other versions with contemporary delivery
mechanisms (cequa – cyclosporine 0.09%)
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Intercellular adhesion molecule-1 (ICAM-1) is found on surface cells of the conjunctiva and cornea
ICAM-1 is overexpressed in dry eye disease LFA-1 and ICAM-1 binding is believed to be
propogate inflammatory cascade on the ocular surface Is believed to do so by T-cell activation and
migration to target tissues
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Lifitegrast applied topically is believed to prevent the interaction between LFA-1 on T-cells and ICAM-1 on the ocular surface
Has been shown to improve both signs and symptoms of dry eye within a 12 week time period
Commercially available as Xiidra 5% concentraton non-preserved sterile unit dose vials
It is a lymphocyte functioning antigen-1 (LFA-1) antagonist
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Blepharitis= lid inflammation
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Exoproteins 1. Exotoxins
a. TSST-1 cause Toxic Shock Syndrome, b. SEA, SEB, SECn, SED, SEE, SEG, SEH, and
SEI cause food poisoningc. ETA & ETB cause Scalded Skin Syndrome
2. Enzymes - nucleases, proteases, lipases,hyaluronidase, and collagenase
The Virulence Factors of Staph aureus
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Stages of DEBS
Stage one - folliculitisStage two - meibomitisStage three - lacrimalitisStage four - lid destruction
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DEBS Stage 1 - Biofilm forms around the lash within follicle
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Stage 2DEBS
Always occurs after folliculitis due to anatomy
MGD
Non-obvious MGD Obvious MGD
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59% of symptomatic CL patients
were converted to
asymptomatic after just one
treatment
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47
66% increase in TBUT after one treatment
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This can vary in signal strength
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-Ten MGD patients with evaporative dry eye and tested positive with InflammaDry-OSDI, NIBUT, meibography and InflammaDry were measured before and after BlephEx treatment (4 week post treatment)- OSDI – 26 (pre-treat) and 10.66 (post-treat)-NIBUT – 6.99 (pre-treat) and 9.53 (post-treat)-Meibography – no change-InflammaDry – positive (pre-treat) and negative (post-treat)
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Permanent Temporary
Pedi-PlugX-SmallSmallMediumLargeX-Large
0.2 mm0.3 mm0.4 mm
Collagen(10-14 days)
3 month0.2 mm0.3 mm0.4 mm0.5 mm
6 month0.3 mm0.4 mm0.5 mm
RecentlyBecameAvailable
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http://www.uofmhealth.org/sites/default/files/healthwise/media/medical/hw/h9991911_001.jpghttp://www.academy.org.uk/tutorials/dilate1.jpg
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IgE
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1. Allergen is taken up, processed and bound to surface of Antigen Presenting Cell (APC).
Allergen
APC
2. Allergen/APC complex activates Th2 lymphocyte which in turn activates naïve B cells to proliferate and differentiate.
ActivatedTh2
Activated NaïveB Cell
3. Plasma Cells (B Cell) secretes allergen specific IgE which bind to sensitized Mast Cells (MC).
Specific IgE
MAST CELL
Thank you to Dr. Gil Pierce
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Acute allergic conditionsSeasonal Allergic Conjunctivitis (Hay Fever) - SACPerennial Allergic Conjunctivitis – PAC
Chronic allergic conditionsVernal Conjunctivitis - VKCAtopic Conjunctivitis - AKCGiant Papillary Conjunctivitis - GPC
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This is where the itch happens
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Signs/Symptoms:
ItchingRednessChemosis Lid swellingTearing
Causes:EnvironmentalGenetic predispositionFindings:Family historyNo eosinophils found in scrapings Spike in tear histamine Normal histaminase function
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Signs/Symptoms:ItchingRednessPhotophobiaKeratopathySPK/UlcersKeratoconusAnterior polar
cataractsMucous dischargeAtopic blepharitis
Causes:Associated with atopic dermatitisMay be perennial Genetic predisposition Environmental antigens
Clinical Findings:Initiates between 20 and 50 years of ageElevated levels of eosinophils, TH2, lymphocytes, and mast cells
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Signs/Symptoms:PtosisRopy mucous dischargePhotophobiaLarge, nonuniform
cobblestone papillaeTrantas dotsLimbal nodulesNeovascularizationShield ulcersItching
Causes:Genetic predisposition, atopySeasonal/perennial allergens (IgE)Nonspecific hypersensitivity
Clinical Findings:Most predominant in males from 3 to 20 years oldIncreased levels of superficial mast cells, eosinophils, and lymphocytesDecreased levels of histaminase
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Signs/Symptoms:Decreased CL toleranceBlurred visionForeign body sensation Small, uniform papillae
on upper tarsal plateThick mucous build-up
Causes:Repeated mechanical irritation caused by:
Contact lens edgeExposed suturesExtruded scleral buckleOcular foreign bodies
Aggravated by concomitant allergyCan also aggravate ocular allergy
Clinical Findings:Increased chronic inflammatory cells
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RGP’s
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Topical Medications Antihistamine/ Mast Cell Stabilizer Combinations
Blocks Histamine receptors on blood vessels, nerve endings, etc
Inhibits histamine degranulation from sensitized mast cells so that when these cells are challenged with antigen, they do not degranulate
Patanol, Pataday, Elestat, Zaditor, Lastacaft, Bepreve
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0.1% 0.2% 0.7%
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IgE
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www.aldeyra.com Aldehyde is a product of metabolism Normally rapidly broken down With inflammation, is produced in quantities that are
difficult to breakdown efficiently NS2 – an aldehyde trap molecule currently being
investigated
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Bacteria leach toxins and by- products
Bacteria Laden Lens
Toxins Flushed/Eliminated
from Eye
Build up of Toxins
Irritation of SurfaceCornea, Conj, Limbus
Trigger Inflammatory Response
No Flush MechanismIncreased Bacterial Load
Pro-inflammatory status (increase cytokines, IgA, Ect)
Red EyeInfiltration of corneal
periphery/mid-periphery with inflammatory cells from
limbus
Compliments of Dave Kading, OD, FAAO
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Diffuse infiltrative keratitis
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Microbial Keratitis Moderately severe symptoms, (+) corneal
staining, (+) A/C reaction, (+) stromal edema, single infiltrate, purulent discharge
Sterile Corneal infiltrates Minimal to moderate symptoms, minimal corneal
staining, minimal to no A/C reaction, little edema if present, multiple infiltrates, (-) purulent discharge
Diagnostic and Treatment Algorithims for Ocular Surface Disease States; SupplementTo Review of Optometry; Oct 2009.
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The multivariate analysis found the following factors to be significant for the development of CIE’s in contact lens wearers
Reusable contact lenses Extended wear Younger age Silicone hydrogel lenses
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500 patients enrolled with a culture positive bacterial ulcer
All were treated with topical moxifloxacin 1 gt q1hr while awake for 48hrs then 1 gt q2hrs while awake until re-epithelialization occurs followed by 1 gt qid until 3 weeks after enrollment
Srinivasan et al. Corticosteroids for Bacterial Keratitis: The Steroids for Corneal Ulcers Trial (SCUT). Arch Ophthalmol. 2011 Oct. (Epub ahead of print)
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Patients were randomized to either receive topical prednisolone sodium phosphate 1% or placebo after 48 hours of effective antibiotic treatment
Steroid and placebo were dosed: QID for the first week after treatment started BID for the second week after treatment started QD for the third week after treatment started
Srinivasan et al. Corticosteroids for Bacterial Keratitis: The Steroids for Corneal Ulcers Trial (SCUT). Arch Ophthalmol. 2011 Oct. (Epub ahead of print)
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Patients were evaluated every 3 days until re-epithelialization, then 3 weeks and 3 months after enrollment
No differences in BCVA, infiltrate scar size and re-epithelialization rates between test and control arm
Srinivasan et al. Corticosteroids for Bacterial Keratitis: The Steroids for Corneal Ulcers Trial (SCUT). Arch Ophthalmol. 2011 Oct. (Epub ahead of print)
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Subgroup analysis: Those with significantly reduced entering visual acuity (CF
or worse) 0.17 better logMAR improvement with steroids
Ulcers completely covering the 4 mm pupil 0.2 better logMAR improvement with steroids
Srinivasan et al. Corticosteroids for Bacterial Keratitis: The Steroids for Corneal Ulcers Trial (SCUT). Arch Ophthalmol. 2011 Oct. (Epub ahead of print)
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35 year old male called into the office earlier that morning
Has had a painful red left eye for the past 10 days Saw his primary care physician about 1 week ago They prescribed a drop that he has been using qid in
the eye – feels like it is getting worse Meds – none Allergies – NKA Review of Systems - negative
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Mild eyelid hyperemia Preauricular lymph nodes are negative +3 injection OS No corneal staining present; prominent stromal
scar (longstanding) Pupils – RRL; OD>OS IOP – 16mmHg @ 11:00am
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8 per 100,00090% are acute anterior uveitisMajority of primary cases are
idiopathic
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• Cyclooxygenase• COX-1 and COX-2• COX-1 – normal physiological response (stomach)• COX-2 – facultatively expressed - inflammation
• COX produces prostaglandins and thromboxanesfrom arachidonic acid
• Arachidonic acid is produced via phospholipase A
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Is it caused by angle closure? Is it caused by trabeculitis? Is there another entity that is causing elevated IOP? www.gonioscopy.org
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Slit Lamp Evaluation
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Slit Lamp Evaluation
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Slit Lamp Evaluation
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Keratic Precipitates Granulomatous vs. non-granulomatous
Constricted Pupil Iris Nodules
Koeppe’s nodules Pupillary margin
Busaca’s nodules Anterior iris stroma
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Attachment of the iris to the lens Usually secondary to inflammatory components Can create an angle closure through pressure that
builds up behind the iris causing it to bow anteriorly causing a physical obstruction to the angle
Visible white inflammatory debris seen on the lens at the edge of the iris
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Measure intraocular pressure View angles Consider gonioscopy if suspicious of blocked angle
secondary to an iris that is bowed forward
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Slit Lamp Evaluation
posterior synechiea
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Can be decreased Inflammation of the ciliary body Will decrease aqueous production and decrease IOP
Can be elevated Trabeculitis Will increase resistance to outflow and increase IOP Can also be secondary to angle closure
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Thank [email protected]