Transcript Document
•Copious overflowing discharge •Ballooning of lids •Swollen nodes Hyperacute Bacterial Conjunctivitis • • • • • • Sexually active adults Neonates, 24-72 hours after birth Most common cause: Neisseria Gonorrhoeae Urgent condition, can penetrate cornea! Theyer Martin culture Tx: Ceftriaxone 1g IM, adults=5days kids=2days • Also topical fluoroquinolone • Positive papillary response • Beefy engorged vessels Acute Bacterial Conjunctivitis • • • • • Susceptible at any age Staph. Aureus is most common cause Steroids mask evolution of infection Tx: 4th gen fluoroquinilone Very contagious, stay home • Inferior Papillae • Wax/wane Chronic Bacterial Conjunctivitis • Staph epi or Staph. Aureus • Inferior papillae because it has had time to build up • Superior papillary response • (-) lymphnode • Edema > injection Allergic Conjunctivitis • • • • • Chemosis due to histamine breakdown Hyperemia gets worse due to rubbing Itching!!!! PAC: Mast cell stabilizer then combo drug SAC: Combo and sometimes mast cell stabilizer • Steroids great when allergen challenge increases • Giant Papillae upper lid • Trantas’ dots around limbus (not always) Vernal Conjunctivitis • • • • • • • • • • Kids, 90% gone by age 16 1st attack is worst Males 2x more than females Caucasians: palpebral form AA/AI/Latinos: Limbal form Bilateral Sheild ulcer (uncommon) Itching!!! Mast cell stabilizer Steroid great for first attack • Nodule, pinkishwhite • Center of lesion necroses and turns gray Phlyctenulosis • 60% are women and young children • Most likely Staph. Exotoxin from previous conjunctivitis • Big in 1950s due to Tb • Unilateral • Pain, #1 symptom • Inflammatory response, so steroids work • Topical antibiotic to treat conjunctivitis • Oral tetracyline if combo doesn’t work • “wimpy conjunctivitis” Environmental Conjunctivitis • • • • Inflammatory response Multiple causes Disease of exclusion Can use mild steroid for a week to stop complaining, then artificial tear • Attempt to optimize tear quality by management of blapharitis and meibomitis • Follicular response • Vesicles • Tender nodes Primary Herpes Simplex Conjunctivitis • • • • • • • Children 60% of population infected by age 5, 90% by 16 Unilateral, other eye follows in a week Doesn’t scar like zoster Foreign body sensation NO STEROIDS! Zirgan can be used instead of viroptic, doesn’t damage cornea as much • Treat dendritic keratitis with viroptic/vidarabine ointment/ganciclovir gel • HSV dendrites: Rose bengal stains edges Herpes Zoster Conjunctivitis • • • • • Older patients (55+) Hutchinson’s sign on nose Triggered by stress or fatigue May also cause keratitis and uveitis Anti-virals w/in 72 hours then less chance of post herpetic neuralgia • Keratitis is Inflammatory, so treat with steroids (unlike HSV) • Psuedodendrites: Rose bengal stains middle • Inferior follicles • Subconjunctival or petechial hemorrhages (maybe) • SEIs • Pseudomembranes • Tender nodes Epidemic Keratoconjunctivitis • • • • • • • • Young adults Adenovirus 8 (can last days on surfaces) No systemic manifestations Unilateral, then other follows in a week or less R/O herpes, no vesicles or dermatomes Consider any keratoconjunctivitis to be HSV or EKC until proven otherwise Contagious Betadine ophthalmic prep solution • • • • • • • Fever Conjunctivitis Sore Throat Tender nodes Follicles Chemosis Possible SEIs Pharyngoconjunctival Fever • • • • • • Kids between 5-15 Swimming pool conjunctivitis Adenovirus 3 Self limiting, 10-14 days Don’t use aspirin for fever because kid SEI interfere with vision, but not a big deal in kids so don’t treat with steroids • • • • • • Fever Cough Coryza Conjunctivitis Koplik’s spots Inferior follicles Rubeola • • • • • Children under 10 Passed respiratory Highly contagious Paramyxovirus Supportive treatment, no antiviral (it will tear up cornea) • Unilateral follicular conjunctivitis • Granulomas with follicles • Node enlargement • Chemosis • Lid swelling Oculoglandular Syndrome • Cat scratch is most common cause • Lymph node enlargement • Lesion at site of scratch Cat Scratch Disease • Young children about 10, girls>boys • Bartonela Hensulae Bacillus • Lesion at site of scratch appears 3 weeks later • Self limiting • May need oral tetracycline or macrolide • • • • • • Fever Chills Malaise HA Nausea Conjunctivitis, necrotising granulomatous type Tularemia • “Rabbit Fever” Franciella tularensis • Lesion at site of organism entry with adenopathy • Treat with streptomycin • Primary site in lungs Tuberculosis • • • • • Central American, pacific rim Low income, inner city Mycobacterium Droplet spread Treatment: rifampin • • • • Chancre Local adenopathy Uveitis Argyl-robinson Syphilis • Primary: Chancre • Secondary: uveitis, skin rash, flu symptoms • Tertiary: neurosyphilis, argyl-robinson • Tx: penicillin or doxycycline • Conjunctiva shows red nodules that turn pink to purple to black and then necrose Sporotrichosis • • • • “Rose Gardeners Disease” Sporothrix Fungus lives on vegetables or in soil Ulcerating nodules on extremeties and along lymph channels • Tx: local=potassium iodide Systemic=ketoconazole • 60% asymptomatic • 40% fever, myalgia, hilar adenopathy • May progress to chronic pneumonia Coccidiodomycosis • San Joaquin Valley and Southwest US immigrant farm workers (25-55 years old) • Airborne Fungus • ‘94 breakout after big earthquake • If accompanied by arthritis and erythema nodosa then called “valley fever syndrome: • Tx: amphotericin B (very toxic) or ketoconazole • Fever, HA, malaise, sore throat, white patches on back of throat Mononucleosis • • • • • • Young adults, uncommon in >25 Epstein-Barr Virus Acute episodes last from 1-3 weeks Self limiting Symptomatic relief Possible penicillin for related strep tonsillitis • Hamster face • HA, myalgia, fever Mumps • • • • Kids Myxovirus Supportive therapy Vaccination (MMR) at 15 months old • Hard lumps on face and neck • Fever, chills, reduced lung function, chest tightness, cough, weezing Actinomycosis • • • • Men 3x more than women Little bug goes in face Typically bad mouth hygiene HX of dental extraction, abdominal trauma, sinus infection, chronic pneumonia • Tx: oral penicillin or erythromycin • Lungs = primary site • Can involve liver, skin, eyes, parotid glands Sarcoid • Most common in female african americans in US • Granulomatas disease of unknown etiology • Mild cases don’t require therapy • Remits spontaneously • Oral steroids used in severe or chronic cases • Sometimes follicles, sometimes papillae Toxic conjunctivitis • • • • Common = sulfacetamide Usually preservatives in meds (bilateral) Viral toxins (unilateral) Follicles not characteristic of all causative agents • Epinephrine causes adrenochrome deposits (black spots on palpebral conj) • TX: dicontinue all drops etc. • Chronic follicular conjunctivitis • Upper tarsal involvement with follicles • Conjunctival scarring • Pannus • Limbal follicles • Herbert’s Pits Trachoma • Mainly children • Leading cause of blindness in the world because is scars the cornea • Eye is reservoir for C. Trachomatis • Make more susceptible to H. flu and strep pneumoniae • Advanced: basket weave of scarring on upper lid • Herbert’s pit = scarred limbal follicles • Tx: oral tetracyclines, macrolides for kids, triple sulfa is can’t take first two • • • • • Papillary response Follicles upper and lower Micropannus Tender pre-auricular nodes Chronic presentation Inclusion Conjunctivitis • Women 15-24 most susceptible • Also neonatal conjunctivitis • Causes majority of infertility and need a slit lamp to diagnose! • Related to venereal disease • Neotnates will only have papillae since lymph tissue is not mature enough to make follicles • Tx: Erythromycin 500mg PO, QID • Other Tx: oral Tetracycline, Azithromycin • Neonates: tetracycline ointment, oral erythromycin • Prominent limbal arcades • Nodules near limbus Facial/Ocular Rosacea • Women 4x more than men • 20-40s have to rule out dermatitis • Nodules not an acute response, takes a few months • Tx: Doxycyclone, Tetracyclines up to 8 weeks, more anti-inflammatory than steroids with meibomian gland problems and rosacea • Very mild steroid for anti-angiogenesis • May need indefinite maintenance therapy • Bullous blistering • Symblepharon • Keratinization of conjunctiva Benign Mucous Membrane Pemphigoid • • • • • 75% more females, older Unusual condition: 1 in 20,000 Type IV inflammatory reaction No explaination Possible mucoud membrane involvement elsewhere • Diagnosis of exclusion • Tx: ocular lubricants on regular basis • Immunosupressive therapy: Dapsone • Blistering • Skin lesions, black lips • Papular skin eruptions Erythema Multiforme • Uncommon blistering disorder of skin and mucous membranes • Probably immune complex mediated • Kick off most commonly by HSV and sulfa meds • Most severe: Stevens-Johnson Syndrome • Tx: Immunosuppressants, Antobiotic for secondary infections: fluoroquinilone • Self limiting condition