Case Analysis I- Lecture 4

1. Liana Al-Labadi, O.D. Case Analysis I- Lecture 4

2. If you hear hoof beats, thinkhorses—not zebras

3. Case 4: The Irritated Eye • 19yo PM c/o red irritating eyes • Frequency: Constantly (all the time, everyday) • Onset: 1 month ago • Location: Both eyes • Duration: 6 months ago had a similar problem and was given eye drops which made things better • Associated Factors: • Any tearing? Any Discharge? YES- Notices yellow discharge once in a while • Any Itch? YES- my eyes itch all the time and I’m always rubbing them • Any burning sensation? Yes • Are your eyes sticky? Crusty? Watery? Not sure they’re just extremely irritating • Have you been sick lately? No • Any pain? No- more irritation than pain • Do you feel your eyes have become more sensitive to light? Yes • Do you think anything has triggered this? Not sure • Has you vision been affected at all? No my vision is fine • Are you a CL wearer? No • Relief: Tried using AT but not noticing any improvement • Severity: 8/10 itch & irritation

4. DIFFERENTIAL DIAGNOSIS????

5. Case 4: The Irritated Eye • POH: • Negative for HA, DIPL, asthenopia, surgery, trauma, pain, F&F • 6 months ago was diagnosed with some allergy condition of the eye • LEE: 6 months ago by Dr. MazenKhowaira • FOH: Negative for AMD, DR, Glc, Cat • LPE: Never had one • PMH: Negative for DM, HTN, Cancer, Neuro • FMH: Negative for DM, HTN, Cancer, Neuro • MED: None • Allg: NKDA; No seasonal allergies • SH: playing sports; No known exposure to anyone with infectious eye disease • Occupation: Student • No alcohol consumption • Smokes Argeeleh occasionally

6. Entrance Testing????

7. Case 4: The Irritated Eye • Entrance Testing: • DVA (s): 20/20 OD; 20/20 OS • Motility: S&F OD, OS • Confrontations: Full OD, OS • Pupils: 4mm/4mm RRL OD, OS; No APD • Minimal light sensitivity noted • No pain on eye movement • No DIPL • No PAN

8. Additional Testing????

9. Case 4: The Irritated Eye • SLE: • L/L: • Trace papillary reaction OD, OS • No mucous debris OD, OS • Conj: • Tr-1+ temporal para-limbal injection OD,OS • Small temporal calcified concretions/infiltrates OD,OS • K: Clear OD, OS • Iris: Flat & brown OD, OS • AC: No cell & no flare/ D&Q OD, OS • Lens: Clear OD, OS (undilated) • IOP: • ????

10. Case 4: The Irritated Eye http://mednt.jp/index.php/trantas+dots http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Vernal-Keratoconjunctivitis.html

11. DIFFERENTIAL DIAGNOSIS????

12. Case 4: The Irritated Eye • Differential Diagnosis: • Atopic keratoconjunctivitis • Seasonal allergic conjunctivitis • Viral conjunctivitis • Bacterial conjunctivitis • Chlamydial and Gonococcal conjunctivitis • Superior Limbic Keratoconjunctivitis (SLK of Theodore) • Toxic conjunctivitis • Giant papillary conjunctivitis (associated with foreign body or CL wear or chronic inflammation) • Episcleritis or Scleritis • Pterygium • Phylctenulosis

13. ADDITIONAL TESTS???

14. FINAL DIAGNOSIS

15. Case 4: The Irritated Eye • Assessment: • Vernal Keratoconjunctivits (VKC) OU • Plan: • Begin FML ophthalmic solution QID OU x 1 week • then BIDx 1 week then stop • Recommend Cool Compresses OU • Recommen Genteal ATs PRN OU • RTC in 2 weeks for F/U • At F/U consider Patnol BID OU

16. VKC • Major Symptoms: • Ocular itching- usually severe • Minor Symptoms: • Ocular burning • Photophobia • Tearing • Redness • Thick, ropy discharge • Seasonal (spring/summer recurrences) • History of atopy- (asthma, rhinitis, and eczema)

17. VKC • An allergy associated recurrent inflammatory disease • Usually bilateral though asymmetry is common • Two forms exist: • Tarsal VKC • Limbal VKC (less common) • Epidemiology: • <1% of population • Males > Females • Usually seen in young boys • Most common 5-20 years of age • Most common in the springtime (correlating to allergen levels) • Numerous flare-ups during childhood • Predilection for warm/dry climates

18. VKC • Pathogenesis: • The immunopathogenesis is multifactorial. • Classically it has been thought of as a type I IgE-mediated hypersensitivity reaction • It has been suggested that there is cell-mediated Th-2 involvement.

19. VKC • Tarsal VKC Signs: • Large conjunctival papillae under upper lid • Apparent on lid eversion • Usually results in pseudo-ptosis • Limbal VKC Signs: • Limbal & paralimbalconjunctival injection • Broad, thickened conjunctivl nodules near the limbus with white lesions over top aka Horner-Trantas’ dots • Usually there is a confluence of nodules • Most commonly seen at the superior cornea-limbus margin • Usually have a mild, milky-white gelatinous appearance • Trantas’ dots= aggregates of eosinophils & degenerated epitheloid cells

20. Tarsal VKC

21. Limbal VKC http://www.drmalcolmmckellar.co.nz/allergic-eye-disease/what-is-it.html http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Vernal-Keratoconjunctivitis.html

22. VKC • Other Signs? • Corneal involvement in 50% of the cases • Punctate epithelial keratitis • Superficial K pannus • Corneal shield ulcers • Well-delineated, sterile, gray-white infiltrate • Observed in 10% of patients

23. VKC • Complications: (in 6% of patients) • Visual loss from: • K vascularization • K scars • Keratoconus • Steroid-induuced cataracts • Steroid-induced glaucoma

24. VKC Treatment • 4 weeks prior to allergy season begin topical treatment with: • Mast cell stabilizer (i.e. cromolyn sodium 4% QID) • Mast cell stabilizer/Antihistamine: • i.e. olopatadine 0.1% BID OR lodoxamide 0.1% QID) • Antahistamine: (i.e. azelastine 0.05% BID) • If moderate to severe inflammation: • Topical steroid (fluorometholone 0.1% to 0.25% OR lotepredonol 0.5% OR prednisolone acetate 1% OR dexamethesone 0.1% ointment) 4-6 times a day • With the appropriate tapering scheduke • Cool compresses • If shield ulcer: • Topical steroid • +/- topical antibiotic and cycloplegic agent • If not responding to treatment, consider cyclosporine 0.05% BID

25. VKC • Follow-up schedule: • Every 1-3 days in the presence of a shield ulcer • Otherwise every 1-2 weeks • Maintain anti-allergy drops for the duration of the season • Patients on topical steroids should be monitored regularly • Prognosis: • Poor if increased size of papillae • Poor if sever bulbar /limbal VKC