Case presentation of recurrent peripheral infiltrative keratitis


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Case presentation of recurrent peripheral infiltrative keratitis

  1. 1. Case Presentation of Recurrent Peripheral Infiltrative Keratitis (PIK) of Unknown Cause 4/17/13 Northeastern State University
  2. 2. 60’s Caucasian male, red eye OD Medical/ocular hx: • No contact lenses, ocular surgeries or trauma • hx of left orbital pseudotumor (neg CT ‘03) • has mild dry eyes and seasonal allergies • no known autoimmune/collagen vascular dis. • hx of insect bite with rash • past blood work unremarkable • closely followed for > 10 yrs; + hypothyroidism • (NOTHING JUMPS OUT)
  3. 3. Some questions we want answered •Is this red eye infectious? •Is this red eye autoimmune? •Is this red eye blepharitic? Next slide: BEGINS THE EXAM
  4. 4. OCULAR EXAM FINDINGS INCLUDE: • Visual acuity and posterior segment are unremarkable • Left eye never became involved
  5. 5. January 2013 Visits for Right eye 1st wk/visit 2nd week 3rd week 4th week History Red/irritated/burn 1 wk 5/10 tenderness light sensitive Less red/irritated/burn 2/10 tenderness Less light sensitive Less red/irritated/burn 1-1.5/10 tenderness Not very light sensitive Less red/irritated/burn 0/10 tenderness not light sensitive Findings + infiltrates ,(+)tr.staining 2-3+ bulbar injection 3+ cells + infiltrates , (-) staining 1-2+ bulbar injection 1-1.5+ cells Less dense infiltrates mild bulbar injection no cells Less dense infiltrates no injection, (+)pannus A and P Peripheral Infiltr. Keratitis (PIK) Anterior Uveitis (AU) Pred Forte (PF) PIK severe epi/mild scleritis AU PF q1-2hrs/day Cyclo 3x Vigamox 4x PIK severe epi/mild scleritis AU PF 5x/day Cyclo 3x Vigamox 3x Resolving PIK mild episcleritis resolved AU PF 4x/day Stop Cyclo Stop Vigamox Resolving PIK resolved episcleritis PF 3x/day for 2wks, then 2x/day til return RTC 2 days 5 days 1-2 weeks 3 weeks
  6. 6. February/March 2013 Visits for Right eye Mid February 1st wk of March 3rd wk of March 4th week of March History 0/10 tenderness not light sensitive no scalp/jaw pain 0/10 tenderness no complaints Pt did not stop taking PF 0/10 tenderness no complaints Stopped PF as directed 0/10 tenderness not light sensitive mild scalp pain Findings IOP 33 (-) infiltrates (+) lipid deposits Gonio stable/open IOP 32 no change IOP normal 3 brightly staining infiltrates, no ulcer 1+ cell IOP normal 3 minimally staining infiltrates no cells A and P Peripheral Infiltrative Keratitis (PIK) Anterior Uveitis (AU) Pred Forte (PF) Resolved PIK OHTN vs steroid response (hx of 31 untreated pressure) Taper PF for 1 wk then stop PF Same Stop PF immediately Recurring PIK AU PF q2-3hr Cyclo 2x Recurring PIK, resolved AU PF q2-3hr Cyclo 2x Additional Labs in case of worsening/ reoccurrence RTC 2 weeks 2 weeks 5days 2 weeks
  7. 7. BEGIN DIFFERENTIALS 1. Infectious Keratitis OCULAR, LOCAL, MOST SEVERE DISEASE 2. Systemic causes (includes infection) 3. Blepharitis associated disease OCULAR, LOCAL, LESS SEVERE NON INFECTIOUS DISEASE
  8. 8. OCULAR, LOCAL,MOST SEVERE DISEASE BACTERIAL OR FUNGAL KERATITIS ABSENT PRESENT discharge decreased vision epithelial defect hypopyon worse w/ steroid alone
  9. 9. Kanski: Characteristics of INFECTIVE vs STERILE corneal infiltrates Size Tend to be larger Tend to be smaller Progression Rapid slow Epithelial defect Very common and larger when present Much less common and if present tend to be small Pain Moderate to severe mild Discharge Purulent mucopurulent Single or multiple Typically single Commonly multiple Unilateral or bilateral Unilateral Often bilateral AC Rxn Severe mild Location Often central Typically peripheral Adjacent corneal rxn Extensive limited
  10. 10. Features HSV marginal ulcer Staph. marginal infiltrate Etiology Active HSV Immunologic response to staph. antigen Epithelial defect Always Absent (if present, late) Neovasc. Often Never Progressi on Centrally Circumferentially Blepharitis Unrelated Usually Location Any meridian Typically 2, 4, 8, 10 o’clock meridians Skin +/- vesicles blepharitis OCULAR, LOCAL,MOST SEVERE DISEASE
  11. 11. HSV stromal keratitis Seen here but absent in our pt: -INFILTRATE SPREAD CENTRALLY -stromal neovasc. Present (THIS IS IMAGE IS ONE EXAMPLE OF INTERSTITIAL KERATITIS) -not ruled out yet
  12. 12. SYSTEMIC (DISTANT CHANGES) 1. Interstitial Keratitis (IK) -Hallmark are ghost vessels 2. Peripheral Ulcerative Keratitis (PUK) -EPITHELIAL DEFECT
  13. 13. DUANE’s ONLINE Systemic Disease Corneal Change Patho- gnomonic Suggestive (distant disease) Nonspecific (local disease) Infiltrates NONE Crohn's disease (peripheral infiltrate) Acne rosacea and other skin diseases (FORCED TO INVEST- IGATE) Leukemia (marginal infiltrates and deposits) Blepharitis associated marginal keratitis (ADDRESS LATER) Interstitial Keratitis NONE Syphilis MANY OTHERS (ADDRESS NEXT)
  14. 14. Hallmark of Interstitial Keratitis Stromal Ghost vessels/neo
  15. 15. Interstitial Keratitis Bacterial infection Parasitic infection Syphilis (could be latent) No skin changes, no Tuberculosis (neg Tb tests) diarrhea, and no contact Leprosy (skin) lens wear Lyme disease (+ hx insect bite with rash) Brucellosis (no fever) Trachoma (no conj scar) Viral infection Systemic disease Herpes simplex virus Cogan's syndr.(hearing okay) Herpes zoster virus (skin) Sarcoidosis (neg. chest XR) Epstein-Barr virus (no symp) Lymphoma (no symptoms) Mumps (no symptoms) Measles (skin) HTLV-1 (no demyelinating)
  16. 16. Kanski: Peripheral Ulcerative Keratitis THINNED CONSIDERABLY
  17. 17. Peripheral Ulcerative Keratitis ONLY SHOWING DIFFERENTIALS NOT ALREADY DISCUSSED Parasitic infection Ocular Superior limbic keratoconj. Systemic Rheumatoid arthritis (negative) Bacterial infection Wegener’s Gran. (neg ANCA) Syphilis (could be latent) Lupus (neg ANA 2002) Viral infection Malignancy (hx of bladder) Herpes simplex virus Lupus (neg ANA 2002) Hepatitis C (negative 1999) Inflam. bowel dis (negative colonoscopy) AIDS (normal WBC 2013) Others (including Sjogren’s)
  18. 18. I. Blepharitis Assoc. Keratitis includes: 1. Marginal keratitis 2. Phlyctenulosis 3. Ocular Rosacea LOCAL CAUSES
  19. 19. I. Blepharitis Associated Keratitis ABSENT PRESENT Less than 2 clock hours of the peripheral cornea Less ulcerative tendency Does not progress centrally LOCAL CAUSES
  20. 20. Signs of blepharitis ABSENT MILDLY PRESENT crustiness, collarettes, flaking telangiectasia of eyelids and face chronic papillary conjunctivitis meibomian gland dysfunction LOCAL CAUSES
  21. 21. Marginal keratitis ABSENT PRESENT surrounded by 1mm clear zone Anterior stromal infiltrate Usually less than 1 clock hour long Predilection for 2, 4, 8, 10 o’clock positions In some cases multiple infiltrates can coalesce to form a larger ring infiltrate LOCAL CAUSES
  22. 22. Kanski: Marginal Keratitis
  23. 23. Phlyctenulosis ABSENT PRESENT pinkish white nodule usually originating at limbus as lesion evolves the elevated nodule ulcerates recurrent lesions extend farther toward central cornea LOCAL CAUSES
  24. 24. LOCAL CAUSES Ocular Rosacea ABSENT PRESENT some infiltrates ulcerate and can perforate cutaneous signs need not be severe for ocular involvement diffuse gray opacification of peripheral stroma with superficial vascularization Severe cases develop recurrent peripheral infiltrates central to peripheral vascularization
  25. 25. Kanski: Ocular Rosacea
  26. 26. Severe cases develop recurrent peripheral infiltrates central to peripheral vascularization
  27. 27. Kanski: Summary of characteristics of chronic blepharitis Anterior blepharitis Posterior bleph. Feature Staphylococcal Seborreic Lashes Deposit Hard Soft Loss ++ + Distorted/trichiasis ++ + Lid Margin Ulcer + Notch + ++ Cyst Hordeolum ++ Meibomian ++ Conjunctiva Phlyctenule + Tear Film Foaming ++ Dry eye + + ++ Cornea (phlyctenules not included) Punctuate erosions + + ++ Vascularization + + ++ infiltrates + + ++ Assoc. Disease Atopic disease Seb. dermatitis Acne Rosacea Marginal Keratitis clear zone
  28. 28. Some questions we want answered •Is this red eye infectious? •Is this red eye autoimmune? •Is this red eye blepharitic? •None have been answered completely but we have identified the next steps
  29. 29. To address infection & autoimmunity: • herpes antibody titers • Lyme titer • FT-ABS, VDRL • Culture the infiltrate • antithyroid peroxidase antibodies • Anti SSA and anti SSB • Rheumatologic consultation
  30. 30. To address blepharitic causes: •Antibiotic ointment •Educate pt to greater attention to lid hygiene •Responsiveness to doxycycline