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Goals for Today

Goals for Today. Hypersensitivity Rxn Phylctenules Marginal Corneal Infiltrate Angular Bleph Rosacea Ocular Rosacea Molluscum contagiosum Varicella – Chicken Pox Bleph Varicell – Zoster Herpes Zoster Ophthalmicus. Primary Herpes Simplex Allergic Lid Disease Type I Type IV

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Goals for Today

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  1. Goals for Today • Hypersensitivity Rxn • Phylctenules • Marginal Corneal Infiltrate • Angular Bleph • Rosacea • Ocular Rosacea • Molluscum contagiosum • Varicella – Chicken Pox Bleph • Varicell – Zoster Herpes Zoster Ophthalmicus

  2. Primary Herpes Simplex • Allergic Lid Disease • Type I • Type IV • Lid Infestation • Demodex • Phthiriasis

  3. G. Hypersensitivity reactions associated with staphylococcal blepharitis • 1. Background • a. Staphylococcal exotoxins may cause hypersensitivity reactions • 1) Allergic responses of conjunctiva and cornea to chronic exotoxin release • a) Phlyctenules • b) Marginal corneal infiltrates • 2) Allergy responses occur usually over days and weeks, rather than hours

  4. 2. Phlyctenules • a. Cell-mediated allergic response of conjunctiva and/or cornea to staphylococcal exotoxins, tuberculosis, or gastro-intestinal parasites • 1) Nodular eruption of leukocyte infiltration • 2) Locations of phlyctenules • a) Conjunctiva • b) Limbus • c) On cornea (least common location)

  5. b. See section in "Conjunctiva" for signs, symptomatology, and treatment of phlyctenules • 3. Marginal Corneal Infiltrates • a. Neutrophils (polys) chemotactically drawn into cornea from limbal circulation, in response to staphylococcal exotoxins acting as antigens

  6. 1) At inferior limbus, near lid margin • 2) Tear film bathes cornea with exotoxins • 3) Corneal staining is frequently seen in the area, typically inferior third of the cornea • 2. See section in "Cornea" for signs, symptomatology, and treatment of marginal corneal infiltrates

  7. H. Angular Blepharitis • 1. Background • a. Two causative organisms • 1) Moraxella lacunata • 2) Staph. aureus or epidermidis (more common)

  8. b. Various manifestations of moraxella organisms • 1) Angular blepharitis • 2) Follicular conjunctivitis • 3) Corneal ulcer • *

  9. c. Moraxella is "epidemic" in institutional settings • 1) Angular blepharitis in debilitated, elderly, institutionalized patients (alcoholics, etc.) • 2) Follicular conjunctivitis in school settings (previous name "orphanage conjunctivitis")

  10. 2. Signs of Angular Blepharitis • a. Eczematoid reaction (characteristic of angular blepharitis) at lateral canthi • b. Maceration (breakdown of tissue due to continued exposure to moisture) • c. Red lid margins at outer canthi • d. Lash scaling typical of staphylococcal or seborrheic blepharitis is NOT specific for angular blepharitis • e. Epiphora from senile ectropion may exacerbate the maceration

  11. 3. Symptoms of Angular Blepharitis • a. Chronic lid irritation • b. Possible itching • c. Skin repeatedly drying out, scaling, then cracking open

  12. 4. Treatment of Angular Blepharitis • a. Differential diagnosis between Moraxella and staphylococcal infections • 1) Institutional setting suggests Moraxella • 2) Impossible to establish identity of microbe without culture

  13. b. Antibiotic ointment to involved area, BID to QID • 1) For Staph., use bacitracin or erythromycin • 2) For Moraxella, use sulfacetamide, neomycin, erythromycin, or polymyxin B; 1O% sulfa-cetamide, Neosporin, erythromycin or Polysporin ointments • 3) If identity of microbe not clear, use bacitracin and polymyxin B (Polysporin)

  14. c. Zinc sulfate solution, BID to QID • 1) Available in Vasoclear A, Clear Eyes ACR, Visine A.C. or in Zincfrin drops • 2) Apply with cotton tipped applicator • 3) Astringent action reduces maceration • d. Culture and sensitivity testing if both antibiotic ointments and zinc drops are ineffective

  15. e. Moraxella are uncommon, staphylococci are common • 1) Empiric therapy: use zinc drops and Polysporin ointment • 2) If therapy is unsuccessful, obtain culture • 3) Check compliance with therapy regimen

  16. 4. Rosacea • a. Background • 1) Unknown etiology • 2) Presents primarily on face • 3) Different from acne juvenilis since limited mostly to face; rosacea does not involve chest or back

  17. 4) Flushing and rhinophyma, specific for rosacea, are not seen in acne juvenilis • 5) P. acnes and other microbes not active in rosacea • 6) Comedos in acne juvenilis not specific for rosacea • 7) Extremes of temperature (hot or cold), hot beverages, and exertion increase vasodilation and facial flushing in rosacea

  18. 8) Presents as facial rosacea, ocular rosacea, or oculo-facial rosacea (study in 1953) • a) Facial rosacea presents first in 55% • b) Ocular rosacea [severe, specific, classic] presents first in 20% • c) Ocular and facial rosacea present simultaneously in 25% • d) Much greater overlap with milder forms of ocular and facial rosacea

  19. 9) Facial rosacea about 2X more frequent in women than in men, though men are afflicted with more severe presentations than women • 10) Ocular rosacea incidence equal between the sexes

  20. b. Facial Rosacea • 1) Areas involved • a) Blush areas of face (cheeks primarily) • b) Also nose, chin, and forehead • c) Superficial telangiectasias • 2) MILD VARIETY = "telangiectatic stage" • a) Simple redness, "ruddy complexion" • b) Face blushes and flushes easily

  21. 3) MODERATE VARIETY = "papular-pustular stage" • a) Single or multiple lesions, wax and wane • b) Papules perhaps more common • 4) SEVERE VARIETY = "glandular hyperplastic stage" • a) Overgrowth of sebaceous and connective tissue of nose (rhinophyma) • b) "W.C. Fields nose"

  22. c. Ocular Rosacea • 1) Multiple ocular presentations • a)Almost all presentations are non- specific • b) Lid manifestations very common • c) Tear film disturbances very common • d) Conjunctival presentations less common • e) Corneal manifestations uncommon to rare • f) Anterior uveitis very uncommon

  23. 2) Lid manifestations of ocular rosacea • a) Chronic blepharitis (similar to staphylococcal type) • b) Meibomitis (frequently primary type of meibomitis) • c) Telangiectatic vessels on lid margins • d) Chalazia and hordeoli

  24. 3) Tear film manifestations of ocular rosacea • a) Frothing • b) Quick TBUT • c) Dry eye and foreign body symptoms

  25. 4) Conjunctival manifestations of ocular rosacea (in decreasing order of frequency), per Catania, "Primary care of the anterior segment" • a) "Dry eye" conjunctivitis • b) Tearing and serous discharge with conjunctivitis • c) Prominent limbal arcades (telangiectasias) • d) 36O degree superficial circumcorneal flush • e) Nodules (gray, vascularized), near limbus, self-limiting

  26. 5) Corneal manifestations of ocular rosacea (in decreasing order of frequency and increasing order of specificity for ocular rosacea) • a) Peripheral SPK • b) Pannus, superficial, about 1-2 mm over limbus • c) Neovascularization (360 degree anterior stromal) • d) Epithelial edema (peripheral, diffuse) • e) Microcysts (peripheral and diffuse)

  27. f) Peripheral EBMD changes (map-dot- fingerprint), not in typical central location • g) Ill-defined SEI's (peripheral) • h) Peripheral (to diffuse) anterior stromal infiltration and hazing, often triangular in shape when near limbus • i) Peripheral corneal thinning • 6) Ocular rosacea changes do not occur synchronously with facial rosacea changes

  28. d. Underdiagnosis of Ocular Rosacea • 1) Easily missed since the doctor fails to examine the whole face of the patient • 2) No laboratory or histopathological tests

  29. 3) Facial lesions need not be severe for rosacea to be present; mild presentations can be dismissed when their recognition would assist in diagnosing oculo-facial rosacea in a patient with non-specific ocular findings (blepharitis, meibomitis) • 4) No definitive criteria exist at present for ocular rosacea; Browning and Proia (Surv Ophthal 1986; 31:145-158) suggest a weighted scale for diagnosis

  30. Clinical sign or symptom Points • rhinophyma 20 • pustules 9 • papules 9 • facial telangiectasia 8 • facial erythema 8 • corneal new vessels 3 • corneal scarring or thinning 3 • recurrent chalazia 2 • recurrent hordeola 2 • blepharitis 1 • conjunctivitis 1 • meibomian gland dysfunction 1 • short BUT 1 • iritis 1 • burning or tearing 1 • facial flushing 1 • clinical suspicion 6-10 points • tentative diagnosis 11-19 points • probably diagnosis 20 or more points • certain diagnosis 20 or more points with concurring opinion of dermatologist

  31. e. Treatment of Rosacea • 1) Treat FACIAL ROSACEA similarly to acne juvenilis • a) Peeling agents to enhance turnover of skin and restore normal skin

  32. b) Tetracycline (PRIMARY THERAPY) • i) 250 mg QID, up to 8 weeks • ii) Slowly taper down to 250 mg QD or QOD • iii) Doxycycline is excellent alternate therapy; BID dose, improved compliance • iv) Action may be anti-inflammatory, with reduction of FFA's • v) Short course of therapy: 250 mg PO, TID for 3 weeks; then 250 mg PO, once daily for 3 weeks

  33. c) Isotretinoin (Accutane) under FDA investigation for rosacea, not approved • d) Metro-Gel (topical metronidazole)

  34. 2) Treatment of OCULAR ROSACEA • a) Treat chalazia, hordeola, meibomitis, and blepharitis with standard regimens • b) Artificial tears on REGULAR BASIS, QID or more frequently • c) Mild steroid for peripheral keratitis • i) 0.12% prednisolone acetate, BID • ii) Too strong a concentration will lead to corneal melting and perforation • d) Oral therapy (tetracycline) often improves ocular manifestation

  35. 3) Patient education • a) Chronic condition which is treatable • b) Avoid extremes of temperature (hot and cold), hot beverages and circumstances which increase vasodilation and facial flushing

  36. 5. Retinoid therapy • a. Tretinoin (Retin-A) • 1) Actions • a) Decreases cohesiveness of follicular epithelial cells, reducing comedo formation • b) Stimulates cell mitosis and turnover

  37. 2) Cautions • a) No oral use, topical use only • b) Definite risk of sunburn • c) Multiple reactions that are typical • i) Redness and peeling skin • ii) Exacerbation of deeper lesions • iii) May see no benefits for 2-6 weeks • d) USE QHS ONLY • e) Avoid other peeling agents • f) Avoid drying soaps, cosmetics, astringents

  38. 3) Formulations of Retin-A • a) gel 0.01% and 0.025% • b) liquid 0.05% • c) cream 0.05% and 0.1% • 4) Drug of choice for OBSTRUCTIVE ACNE • 5) Other uses: • a) Actinic keratoses • b) Periorbital comedones

  39. b. Isotretinoin (Accutane) • 1) Actions • a) Inhibits sebaceous gland function • b) Inhibits keratinization • 2) Indicated only for CYSTIC ACNE at present

  40. 3) Side effects • a) Cheilitis (dry, chapped lips) 90-95% • b) Conjunctivitis in 40% of cases • c) Musculoskeletal complaints • d) Dry skin, dry mouth, dry nose, dry eyes • e) Epistaxis (nose bleeds) • f) Corneal opacities, about 7% of cases • g) Pseudotumor cerebri

  41. h) Decreased night vision • i) Lipid disorders • i) Elevated triglycerides, about 25% • ii) Decreased HDL, about 15% • iii) Elevated cholesterol, about 7% • j) Elevated erythrocyte sedimentation rate (ESR) • k) Virtually all side effects are reversible upon discontinuing therapy

  42. 4) Pregnancy is ABSOLUTE CONTRAINDICATION • a) Definite teratogenicity • b) Fetal abnormalities include hydrocephalus, microcephalus, microphthalmia • c) Women must have pregnancy testing prior to starting therapy and use two methods of contraception during course of therapy and for one month before starting and one month after stopping therapy.

  43. 5) Monitoring lipid disorders • a) Monitor triglycerides regularly • b) Weight loss, reduced alcohol and fat intake may allow a patient to continue on a lower dose of Accutane without stopping therapy

  44. J. Viral inflammations • 1. Molluscum contagiosum • a. Background • 1) Pox virus which can cause epithelial lid growths due to inflammation of the skin of the lid • 2) Usually children, can occur in adults • 3) Mildly contagious - can be picked up by manipulation of the core of the lesion • 4) Grows over a 1-2 month period after inoculation

  45. b. Clinical presentation • 1) Symptoms • a) Lid growth(s) (see below) • b) Follicular conjunctivitis (probably toxic) "red eye" • c) Corneal epithelial disruption (probably toxic) "scratchy eye" - diffuse or marginal epithelial disruption • d) Can be conjunctival lesions "lump on eye"

  46. 2) Signs • a) Lid growth is a small grey-white nodule with central light colored (usually) core which can be removed • b) Lesion may be filled with a cheesy material • c) Slowly grows over 3 mos to 2 yr period. Can have discharge which produces ocular irritation (follicular conjunctivitis)

  47. c. Treatment • 1) Treatment of the corneal or conjunctival effects involves treatment of the lid growths • 2) Treatment of lid growth • a) Referral for surgical excision • b) If appears like BCC, SCC needs excisional biopsy

  48. d) Will often resolve spontaneously • e) Central core is emitted before resolution • f) Evaluate carefully and rule out BCC or SCC • g) May also mimic keratoacanthoma but keratoacanthoma is larger, more quickly progressive

  49. c) Can remove the central core (which contains viral material) as follows: • i) Clean surface with alcohol wipe • ii) Loosen core with sharp instrument such as spud • iii) Squeeze out contents

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