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Now that you Established the Cause – How do you Treat?

Now that you Established the Cause – How do you Treat?. Moderate – Topical antibiotics 6 – 8 times daily tapering to QID x 7 to 10 days. Severe – may be at risk of cellulitis and will require topical and oral antibiosis. Topical steroids for concurrent inflammation?

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Now that you Established the Cause – How do you Treat?

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  1. Now that you Established the Cause – How do you Treat? • Moderate – Topical antibiotics 6 – 8 times daily tapering to QID x 7 to 10 days. • Severe – may be at risk of cellulitis and will require topical and oral antibiosis. • Topical steroids for concurrent inflammation? • Clinical Pearl – Avoid Sulfa, Tetracyclines and Chloramphenicol.

  2. Some Choices to Consider: Trimethoprim • wide spectrum but no Pseudomonas coverage • 1 gtt QID • Studies show that it is good for kids @ 2 months. • Available with polymyxin B as Polytrim

  3. The Aminoglycosides: • Bacteriocidal against Psedomonas ans some Gram +’s. • Dosage is QID. • Toxic epitheliopathy especially in more frequent dosings. • Neuromuscular blocking activity especially in Myasthenia patients.

  4. Fluoroquinolones: • Most effective ophthalmic antibiotics. • Good for moderate to severe conjunctivitis. • Dosed 6 to 8 times daily tapering to QID over 5 to 7 days. • Numerous studies but the best one is not well established.

  5. Fluoroquinolones:

  6. Hyperacute Conjunctivitis • Most commonly from Neisseria. • Can be from S. aureus, Strept., H. influenzae, Moraxella, E. coli and Pseudomonas. • Sudden, abundantly purulent conjunctivitis with chemosis and hyperemia. • If not treated properly cellulitis, keratitis, ulceration, dacryadenitis and septicemia.

  7. Hyperacute Conjunctivitis

  8. Hyperacute Conjunctivitis

  9. Treatment of Hyperacute Conjunctivitis • Must be treated aggressively: • Topical antibiotics • Oral antibiotics • Injected antibiotics (Ceftriaxone 1 g IM) • Frequent irrigation with saline • Gonoccal conjunctivitis is often found with concurrent Chlamydial infection.

  10. Chronic Conjunctivitis • Difficult to evalutate because symptoms are so nonspecific. • FB sensation, burning, tearing, sticky eyelids… • Conjunctiva is thickened, diffusely red, papillary or follicles. • Rule out Chlamydia, lid disease, HSV and rosacea. • May need culturing.

  11. Chlamydia • Primary organism is Chlamydia trachomatis Types D - K • Very small, obligate intracellular parasite. • Chlamydial infection is the most common sexually transmitted disease in the U.S. • 75% of women and 50% of men have no urogenital symptoms. • One of the most common causes of chronic conjunctivitis.

  12. Inclusion Conjunctivitis • Sexually active adults with follicular conjunctivitis with mucopurulent discharge. • Usually unilateral with sometimes a small nontender preauricular node. • During the second week epithelial keratitis may develop with marginal or central infiltrates. ** Usually superior cornea.

  13. Inclusion Conjunctivitis • Commonly misdiagnosed with a history of multiple topical antibiotics used. • Diagnosis made by laboratory testing: 1) Conjunctival scraping with Giemsa stain 2) Immunodiagnostic studies 3) PCR

  14. Giemsa Stain 1) Scrape the conjunctiva. 2) Place on slide 3) Fix the slide & stain with Giemsa

  15. Polymerase Chain Reaction (PCR) • High sensitivity and specificity for Inclusion conjunctivitis.

  16. Direct Immunofluorescent Antibody Assay

  17. Management of Inclusion Conjunctivitis: Doxycycline – 100 mg twice daily for 7 days. **Remember to avoid using this in pregnant women and children under 8 y.o. Use instead: Erythromycin 500 mg PO QID x 7 d Azithromycin 1000 mg PO once or Amoxicillin 500 mg PO TID x 7 d

  18. Trachoma • Chlamydia trachomatis Types A - C • A serious world health problem. • In the U.S. there are small pockets found in the southwest in Native Americans.

  19. Trachoma: • Early in the disease it is a chronic follicular conjunctivitis. • Later the reaction appears more papillary • Patients begin to experience photophobia, tearing and a mucopurulent discharge. • Follicles form at the limbus. • Keratitis begins superiorly with infiltrates and ulcerations.

  20. Trachoma: Continued • Conjunctiva scarring replaces the initial inflammatory signs. (Arlt’s Line) • This can lead to trichiasis & entropion which inturn can cause corneal ulceration and scarring. • The limbal follicles involute (Herbit’s pits) which is pathognomonic for trachoma

  21. Trachoma: Arlt’s Line: Herbit’s Pits:

  22. Treatment of Trachoma • Tetracycline – 250 mg QID x 3 weeks. • Erythromycin – 500 mg QID *No changes seen for 3 to 4 months. *Reinfection rates are high. • Azithromycin single dose. • Surgery for the scarring (PK) or for the entropion and trichiasis.

  23. Viral Conjunctivitis

  24. Viral Conjunctivitis • Manifests as a Follicular Conjunctivitis. • A follicular conjunctivitis can be Acute or Chronic. • Follicles are rare on the Bulbar conjunctiva but can sometimes be seen limbally. • An acute follicular conjunctivitis is almost pathognomonic of viral involvement.

  25. Viral Conjunctivitis • Chronic Follicular conjunctivitis can be seen in… 1) Trachoma 2) Some long standing allergies

  26. Viral Conjunctivitis

  27. Viruses of Concern: • Adenovirus • Herpesvirus • Picornavirus • Influenza Virus A • Varicella Zoster Virus

  28. Adenoviruses • A DNA virus with 51 serotypes with about 33 types causing disease. • Virus can replicate lytically • 1 million viruses produced per host cell killed. • Patients feel sick. • Viruses that cause chronic or latent infections tend to reproduce with smaller numbers of viruses being released and therefore patients don’t feel as sick. • Cause an Acute Respiratory Disease (ARD), Pharyngeal Conjunctival Fever (PCF) and Epidemic Keratoconjunctivitis (EKC)

  29. Pharyngeal Conjunctival Fever (PCF) • Caused by Adenovirus type 3 and 7. • Symptoms consist of: Follicular conjunctivitis Sore throat Fever Runny nose Pre-auricular adenopathy • Most commonly seen in children.

  30. Pharyngeal Conjunctival Fever • Acute Follicular conjunctivitis. • Pharyngitis • Fever • Pre-auricular lymphadenopathy (Nontender)

  31. Epidemic Keratoconjunctivitis (EKC) • Caused by Adenovirus type 8, 19 an 37. • After exposure the patient experiences inflammed sticky lids in 4 to 24 days and the keratitis can last 2 to 8 weeks. • 5 to 8% will have concurrent respiratory symptoms as well.

  32. Epidemic Keratoconjunctivitis

  33. Epidemic Keratoconjunctivitis What distinguishes EKC from PCF is… In EKC: 1) Subepithelial infiltrates 2) Tender palpable pre-auricular nodes 3) Can occur in any age group.

  34. EKC Subepithelial Infiltrates (SEI’s)

  35. Epidemic Keratoconjunctivitis • Pain • Photophobia • Watery eyes with blurred Vision • Moderate to severe redness • SEI’s 6) Pseudomembrane 7) Lymphadenopathy

  36. Treatment of Adenoviral Infections • Most cases resolve in about 2 to 3 weeks. • Supportive therapy (cold compresses, lubricants). • Betadine 5% lavage • Steroids may limit the infiltrates and decrease pseudomembrane formation. i gtt every 1 – 2 hours is controversial.

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