1. Case Presentation of
Recurrent Peripheral
Infiltrative Keratitis
(PIK) of Unknown Cause
4/17/13
Northeastern State
University

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)

6. 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

7. OCULAR EXAM FINDINGS INCLUDE:
• Visual acuity and posterior
segment are unremarkable
• Left eye never became involved

8. 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

12. 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

15. 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

16. OCULAR, LOCAL,MOST SEVERE DISEASE
BACTERIAL OR FUNGAL KERATITIS
ABSENT PRESENT
discharge
decreased vision
epithelial defect
hypopyon
worse w/ steroid alone

17. 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

18. 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

19. 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

20. SYSTEMIC (DISTANT CHANGES)
1. Interstitial Keratitis (IK)
-Hallmark are ghost vessels
2. Peripheral Ulcerative
Keratitis (PUK)
-EPITHELIAL DEFECT

21. 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)

22. Hallmark of Interstitial Keratitis
Stromal Ghost vessels/neo

23. 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)

24. Kanski: Peripheral Ulcerative Keratitis
THINNED CONSIDERABLY

25. 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)

26. I. Blepharitis Assoc. Keratitis
includes:
1. Marginal keratitis
2. Phlyctenulosis
3. Ocular Rosacea
LOCAL CAUSES

27. I. Blepharitis Associated Keratitis
ABSENT PRESENT
Less than 2 clock
hours of the
peripheral cornea
Less ulcerative
tendency
Does not progress
centrally
LOCAL CAUSES

28. Signs of blepharitis
ABSENT MILDLY PRESENT
crustiness,
collarettes, flaking
telangiectasia of
eyelids and face
chronic papillary
conjunctivitis
meibomian gland
dysfunction
LOCAL CAUSES

29. 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

30. Kanski: Marginal Keratitis

31. 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

32. 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

33. Kanski: Ocular Rosacea

34. Severe cases develop
recurrent peripheral
infiltrates central to
peripheral vascularization

35. 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

36. 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

37. 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

38. To address blepharitic causes:
•Antibiotic ointment
•Educate pt to greater
attention to lid hygiene
•Responsiveness to
doxycycline