Challenging Anterior Segment Cases

Challenging Anterior Segment
Cases
Benjamin P. Casella, OD, FAAO
[email protected]
Disclosures
• Have lectured or been a consultant for:
– Allergan
– Carl Zeiss
– Hydrogel Vision
31yoWM
• “My eye is irritated, and I want
you to fix it!!!”
• “I’ve tried Tobradex, and it didn’t
help.”
31yoWM
Questions???
31yoWM Management
• Referred patient back to his retinal
surgeon for repair of his displaced scleral
buckle
• Signs and symptoms disappeared
thereafter
Eye Irritation
The Requisites
Why Is This Eye Irritated?
• 4 grossly over-simplified and ridiculously
generalized categories:
– Inflammatory
– Infectious
– Mechanical
– Hemorrhagic
Inflammation
• 3 points to note
– Every part of the anterior segment can
become inflamed
– Inflammation can come in many flavors
– Inflammation can be progressive
Inflammation
• My workhorse anti-inflammatories
– Fluoromethalone (FML)
– Tobramycin/dexamethasone (Tobradex)
– Difluprednate (Durezol)
– Alcaftadine (Lastacaft)
– Oral Ibuprofen (Advil)
– Oral Prednisone
A Word On Steroids
• Suspensions = different pharmacokinetics
on the ocular surface
• Generic prednisolone acetate = issues
with penetration and with staying in
suspension form
• This may be especially important in the presence
of uveitis
A Word On Steroids
• Oral steroids are readily available
generically in 5mg or 10mg tablets
– Cheap
– Math is easy with tapering
– Loading dose is typically 40-60mg
Dry Eye Disease
• Dry eye disease is progressive and has
inflammatory components, causes, and
sequelae
• Dry eye disease can be owned – from
start to finish – by Optometry
Dry Eye Disease
• My dry eye workhorses
– Topical cyclosporine (Restasis)
– 1 drop – easy dosing – no preservative – treats all layers
of the tear film – no long term fears
– Oral Doxycycline
A Word On Doxycycline
• Widely used for MGD
• Typically 50mg to 100mg q.d. for a couple
of months and implement omega 3 FA
supplementation concurrently
• 20mg available
• It is a tetracycline
– Not for kids, pregnant, nursing, pt’s on blood
thinners
Infection
• 3 points to note
– Every part of the anterior segment can
become infected
– Infections can come in many flavors
– Infections can be progressive
Infection
• My workhorse anti-infectives
– Polymixin B/trimethoprim (Polytrim)
– Tobramycin/dexamethasone (Tobradex)
– Oral Levofloxacin (Levaquin)
– Oral Azithromycin (Zithromax)*
* when I need it
– Oral Amoxicillin/Clavulanate (Augmentin)
55yoWM
• “My eye is irritated, and I want
you to fix it!!!”
55yoWM
Questions???
Antivirals
• Trifluridine
– Generic for Viroptic Readily available from
several manufacturers
– Q2h dosing
– Corneal toxicity!!!
Antivirals
• Zirgan
• Gancyclovir ophthalmic gel
• Much less corneal toxicity
• 5x/day until ulcer heals, then t.i.d. x 1 wk
55yoWM
• “However, there’s some stuff that
I’m allergic to.”
Antivirals
What if you need an oral antiviral???
Herpes Simplex Virus (HSV)
• World’s most popular virus???
– Most humans infected by adolescence
– Type 1 and 2
• Based on where they generally go dormant
HSV
• Acyclovir (Zovirax)
• 400mg p.o. 5x/day x 7-10 days
• 400mg p.o. b.i.d. for maintanence
• Valacyclovir (Valtrex)
• 1000mg p.o. b.i.d. x 7-10 days
• 500/1000mg p.o. q.d. for maintanence
• Famcyclovir (Famvir)
• 250mg p.o. t.i.d. x 7-10 days
• 250mg p.o. b.i.d. for maintanence
Oral Antivirals
• Adverse effects
–
–
–
–
Nausea
Rash
Diarrhea
Headache
• Contraindications
– Hypersensitivity
– Renal dysfunction (high doses)
– Intolerance
Herpetic Infections
Vesicles are a sign
of herpetic infection
Not To be Confused With HZ O
• Herpes zoster ophthalmicus
– Varicella-zoster virus
– Rash / vesicles / ulceration
– Patient contagious until lesions crust
– Headache / fever / malaise x 2-3 days prior
– Start therapy w/in 3 days of symptom onset
• However, treat even if outside that window
• Big reason to treat is to prevent post-herpetic
neuralgia
HZO
• Conjunctivitis most common ocular
manifestation
– Can also have uveitis, episcleritis, keratitis,
scleritis, optic neuritis, retinitis, cranial nerve
palsies
– Hutchinson sign increases risk of ocular
manifestations (especially uveitis)
HZO
• Acyclovir
• 800mg p.o. 5x/day x 7-10 days
• Valacyclovir
• 1000mg p.o. t.i.d. x 7-10 days
• Famcyclovir
• 500mg p.o. t.i.d. x 7-10 days
Post-herpetic Neuralgia
• Analgesics
• Steroids
• 10-60mg p.o. (divided b.i.d., etc.)
• Tapered over 2-3 weeks
– Capsaicin ung (Zostrix)
– Tricyclic antidepressants
– Gabapentin (Neurontin)
– Lidocaine patch
Antivirals
• Topicals are pregnancy category C
• Orals are pregnancy category B!!!
Antivirals
• Herpetic Eye Disease Study
– Any herpetic infection can be treated orally
– Corneal considerations???
Management of 55yoWM
• Oral valacyclovir 1000mg b.i.d. and return
in 3-5 days for follow-up
• Patient enjoyed complete resolution of the
lesion and now goes to a cornea specialist
for his eye care as per the wishes of his
primary care physician
20yoWF
• My eye is irritated, and I’m pregnant
• Oh yeah, and this has been going on for 4
months…
20yoWF
Questions???
And…I’ve been several other places
and tried “everything”
Chlamydia Conjunctivitis
• Azithromycin
– Zithromax or “Z pak” (500mg q.d. on day one,
then 250mg q.d. on days 2-5)
– 1 gram single dose for Chlam ydia
trachom atis (repeat regular dose if
needed)
“Mechanical” Eye Irritation:
Foreign Bodies
• Inverting lids will tell you a lot
• If metal (or any penetrating substance) is
suspected, dilation is mandated
• Never pass up the opportunity to tell some
to wear safety glasses
Foreign Bodies
• What would you do for the lesion?
• What would you do for the pain?
Hemorrhagic Irritation
• Subconjunctival hemorrhage
– History will tell you a lot
– Stain to check for abrasions isn’t a bad idea
– Be wary of recurrences with no clear cause
– Get a look at the optic nerves
Terson Syndrome
Terson Syndrome
• Ocular hemorrhages (typically vitreous or
conjunctiva) in association with
subarachnoid hemorrhages
• Subarachnoid hemorrhages carry a
considerable risk of mortality
54yoAAM
• “My eyes are really irritated, and I’m
currently incarcerated for theft.”
54yoAAM
Questions???
54yoAAM Management
• Pt does take Xalatan, but has been doing so for
years
• So…
– FML q2h OU and rtc x 1 week
– 1 Week later: much better
– Recurrence after tapering gtt
54yoAAM Management
• Get me the newest bottle of latanoprost
and the one before that
• Different manufacturer for the newer
bottle
All Drops Are not Created Equal
• Not even different bottles of the “same”
medication
• Generic latanoprost
– Over 10 companies make it
– One of those companies is Pfizer, who created
Xalatan
26yoAAF
• “Both eyes have been aching lately when I
move them around.”
• Medications include:
– Orthotricycline
– Crestor
– Tylenol 3 (prescribed for eye pain)
26yoAAF Management
• Is it likely to have bilateral retrobulbar
optic neuritis???
– What about her med’s?
26yoAAF Management
• Statins
– Commonly prescribed for hypercholesterolemia
– Can reduce cells’ ability to regulate lactic acid excretion
– Lactic acid build-up from anaerobic respiration is what makes
you sore after working out
– Drinking lots of water can facilitate lactic acid excretion
Thank You!
[email protected]

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