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Keratitis

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Keratitis

  1. 1. SEEING REDA N O V E R V I E W O F I N F E C T I O U S K E R A T I T I S L I B B Y D A U G H E R T Y , P H A R M D C A N D I D A T E M A T T H E W P O S T , P H A R M D , B C P P S C H I L D R E N ’ S H E A L T H C A R E O F A T L A N T A A T S C O T T I S H R I T E U N I V E R S I T Y O F G E O R G I A – A P P E 4 – E M E R G E N C Y M E D I C I N E
  2. 2. KERATITIS • Infection of one or many layers of the cornea • Mostly due to contact lens use, especially with improper use or hygiene • Distinguishing the causative agent is important and difficult • Vision-threatening – Early consultation with ophthalmology is important – Aggressive treatment is warranted
  3. 3. CORNEA ANATOMY • Layer of clear columnar cells that covers the front part of the eye. • Consistent with the sclera • Covers the anterior chamber which includes the iris/pupil. • Corneal epithelium is only 1-2 cells thick • Stroma is made of keratin
  4. 4. PATHOLOGY Damage to the corneal epithelium introduces microflora to the stroma Microflora infect the keratin of the stroma Corneal inflammation attracts neutrophils to the cornea Enzymes released by neutrophils exacerbate inflammatory necrosis Progressive inflammation quickly leads to corneal perforation Wound healing often leaves scarring
  5. 5. PRESENTATION Early/Common • Redness • Rapid onset of mild-moderate pain • Decreased/blurry vision • Photophobia • Tearing Late/Severe • Visible infiltrate(s) • Eyelid edema • Conjunctival inflammation • Hypopyon • Discharge
  6. 6. DIAGNOSIS • Fluorescein Stain – Binds to keratin – Cannot penetrate corneal epithelium – Only binds to the part of the cornea that has lost its epithelium – Illuminates under fluorescent light • Corneal Scraping – Provide anesthesia first – Bacterial and fungal cultures Fluorescein stain applied to eye and washed out with saline. Viewed under cobalt lamp to visualize defects in the corneal epithelium.
  7. 7. INFECTIOUS ETIOLOGIES Bacterial • Singular infiltrate • Solid border Fungal • Large hypopyon • Feathered/fuzzy border • Satellite infiltrates Herpetic • Dendritic lesion Acanthamoebi c • Variety of infiltrates
  8. 8. BACTERIAL KERATITIS
  9. 9. BACTERIAL KERATITIS • Most common form of Keratitis (90-95% of all cases) • Rapidly progressive (2-3 days) • Sight-threatening • Pathogens – Streptococcal spp. – Pseudomonas – Staphylococcus spp. – Atypical bacteria – Anaerobes
  10. 10. RISK FACTORS • LASIK surgery • Contact lens use – Extended wear – Improper hygiene – Sleeping with contacts – Swimming with contacts • Ophthalmic corticosteroids • Corneal injury • Enropion • Chronic dry eye
  11. 11. PRESENTATION SYMPTOMS • Redness • Changes in vision • Pain • Photophobia • Cornea may be clear or hazy • Hypopyon may be present COMPLICATIONS • Corneal thinning – Increases risk for further infection – Increases risk for perforation • Perforation – Infection of the inner eye – Often results in permanent loss of sight – May result in loss of eye entirely
  12. 12. MANAGEMENT • Ophthalmology consult • Corneal scrapings sent for culture, staining and analysis • Topical bactericidal antibiotics – Broad Spectrum • 4th Generation Fluoroquinolone • Fortified Cephalosporin + Aminoglycoside – Frequent Administration • Every hour for at least 24 hours • May reduce to every 2 hours while awake after signs of improvement • Tapered per clinical improvement (per ophthomologist) • Cycloplegia as needed for pain – Atropine 1% 1-2 drops 4 times daily – Cylopentolate (Cyclogyl) 0.5-2% 1- 2 drops every 5-10 minutes – Cyclopentolate/Phenylephrine (Cyclomydril) 0.2% 1 drop every 5- 10 minutes
  13. 13. FLUOROQUINOLONES • 2nd Generation – Ciprofloxacin 0.3% (Ciloxan) – Ofloxacin 0.3% (Ocuflox) • 3rd Generation – Levofloxacin 0.5% • 4th Generatoin – Moxifloxacin 0.5% (Moxeza, Vigamox) – Gatifloxacin 0.5% (Zymaxid) Pros Cons
  14. 14. FORTIFIED ANTIBIOTICS • Aminoglycosides – Gentamicin 14mg/ml (1.4%) – Tobramycin 14mg/ml (1.4%) – Amikacin 2.5% • Cephalosporins – Cefazolin 50mg/ml (5%) – Ceftazidime 50mg/ml (5%) Pros Cons Multiple agents Poor stability Requires compounding Good tolerability Low resistance Broad coverage
  15. 15. FORTIFIED ANTIBACTERIAL EYEDROPS AMINOGLYCOSIDES • Tombramycin and Gentamicin 1.4% – Add 2ml (80mg) of the parenteral solution to the commercially available eyedrops – Stable for 7 days in the fridge (4°C) – Stable for 4 days at room temperature • Amikacin 2.5% – Add 2ml (250mg) of the parenteral solution to 8ml of artificial tears – Stable for 7 days in the fridge (4°C) CEPHALOSPORINS • Cefazolin 3.3% (33mg/ml) – Reconstitute 500mg with 2ml 0.9% NaCl and add to 13ml of artificial tears – Stable for 4 days at room temperature • Ceftazidime 5% (50mg/ml) – Reconstitute 1g with 10ml sterile water – Mix 7.5ml of solution with 7.5ml sterile water – Stable for 7 days in the fridge
  16. 16. FORTIFIED ANTIBACTERIAL EYEDROPS • Vancomycin 31mg/ml (3.1%) – Reconstitute 500mg with 5ml sterile water – Stable for 28 days in the fridge (4°C) • Colistin 0.19% – Add 10ml sterile water to 75mg Colistimethate sodium (Xylistin) powder to make 7.5mg/ml solution – Add 1 ml of the 7.5mg/ml solution to 3ml distilled water to make topical 0.19% drops • Linezolid 2ml/ml (0.2%) – Use the 200mg/100ml parenteral solution directly • Imipenem-Cilastin 1% – Add 10ml sterile water to 500/500mg parenteral solution to make a 50mg/ml solution. – Add 1ml of the 50mg/ml solution to 4ml sterile water to make topical 1% drops – Stable in an amber bottle for 3 days in the fridge (4°C)
  17. 17. ADJUNCTIVE THERAPY STEROIDS • Controversial • Decreases inflammation – Minimizes scarring – Reduces stromal necrosis – Delays wound healing/epithelium regrowth – May increase risk of perforation • Regimens – Dexamethasone 0.15 Q2H – Prednisolone 1% QID • If used, should not be started until after signs of clinical improvement on antibacterial therapy (24-48 hours) ORAL ANTIBIOTICS • Indications – Juxtalimbal ulcer – Perforation – Atypical infections • Regimens – Fluoroquinolones – Cephalosporin/Aminoglycoside – Macrolides
  18. 18. FUNGAL KERATITIS
  19. 19. FUNGAL KERATITIS • Difficult to distinguish from bacterial based on visual exam alone – May be more fuzzy/feathered – May be extra satellite lesions • Often results in more severe disease – Fungal growth is slower, but uninhibited by epithelial membranes – Delays in diagnosis • Pathogens – Candida – Aspergillus – Fusarium
  20. 20. FUNGAL KERATITIS RISK FACTORS • Vegetation – Ocular trauma – Particles • Tropical climate • Immunodeficiency MANAGEMENT • Topical antifungals – Amphotericin B 0.15% – Voriconazole 1% – Natamycin 5% (Natacyn) • Oral antifungals – Fluconazole – Ketoconazole • Cycloplegia • Topical antibiotics
  21. 21. FORTIFIED ANTIFUNGALS EYEDROPS • Amphoteracin B 0.15% – Add 10ml sterile water to 50mg powder for injection. – Add 3ml of solution to 7ml artificial tears – Stable for 7 days in fridge – Stable for 4 days at room temperature • Voriconazole 1% – Mix 2ml Ringer’s Lactate with 200mg lyophilized powder – Stable for 30 days in fridge (4°C) INTRASTROMAL INJECTION • Amphoteracin B 5-10μg/0.1ml • Voriconazole 50μg/0.1ml • For severe disease only – Intensely painful – High risk of systemic absorption/toxicity
  22. 22. VIRAL KERATITISA K A “ H E R P E T I C K E R A T I T I S ”
  23. 23. VIRAL KERATITIS Herpetic Adenoviral • Herpetic Keratitis – Caused by Herpes simplex virus (HSV- 1) – Easily identifiable “dendritic” appearance • Adenoviral Keratitis – Caused by Adenovirus – Occurs most often following adenoviral conjunctivitis – Ocular reaction to adenovirus particles – Small sub-epithelial infiltrates – Self-limiting
  24. 24. HERPETIC KERATITIS BACKGROUND • Most common cause of infectious blindness worldwide • Presentation is exactly the same as bacterial keratitis, except: • Characteristic lesions initially present in a dendritic pattern • Good prognosis if treated MANAGEMENT • Topical antivirals – Ganciclovir (Zirgan) – Trifluridine (Viroptic) • Systemic antivirals – Acyclovir (Zovirax) – Valacyclovir (Valtrex) • Cycloplegia – Atropine – Cyclopentolate (+/- Phenylephrine) • NO STEROIDS!
  25. 25. PARASITIC KERATITISA K A “ A C A N T H A M O E B I C K E R A T I T I S ”
  26. 26. ACANTHAMOEBIC KERATITIS • Extremely Rare • Generally associated with contact lens use while swimming • Has been associated with contaminated contact lens solution • Poor prognosis – Delay in diagnosis – Limited/ineffective therapies – Resilient infection (cysts)
  27. 27. ACANTHAMOEBIC KERATITIS • Systemic antifungals – Voriconazole – Ketoconazole • Topical Biguanides – Chlorhexadine 0.02% – Polyhexamethylene biguanide (PHMB) 0.02% • +/- Topical antiprotozoals (diamidines) – Pentamidine isethionate (Pentam) 0.1% – Propamidine isethionate (Brolene) 0.1% – Hexamidine (Desmodine) 0.1% • Topical antifungals – Natamycin (Natacyn, Pimaricin) – Neomycin (Neo-Polycin) • Cycloplegia • Steroids • Check the CDC website!
  28. 28. REFERENCES • "Acanthamoeba - Granulomatous Amebic Encephalitis (GAE); Keratitis." Centers for Disease Control and Prevention, 22 Oct. 2013. Web. 04 Oct. 2016. • DeLoss, Karen S. "Complications of Contact Lenses." Ed. Jonathan Trobe and Janet L. Wilterdink. UpToDate. Wolters Kluwer, 17 Sept. 2016. Web. 4 Oct. 2016. • Forooghian, Farzin. "Oral Fluoroquinolones and the Risk of Retinal Detachment." Journal of the American Medical Association 307.13 (2012): 1414. Web. • Gangopadhyay, N. "Fluoroquinolone and Fortified Antibiotics for Treating Bacterial Corneal Ulcers." British Journal of Ophthalmology 84.4 (2000): 378-84. Web. 4 Oct. 2016. • Goldstein, Michael H., Regis P. Kowalski, and Y.jerold Gordon. "Emerging Fluoroquinolone Resistance in Bacterial Keratitis." Ophthalmology 106.7 (1999): 1213-318. Web. 4 Oct. 2016.
  29. 29. REFERENCES • Hillenkamp, Jost, Rainer Sundmacher, and Thomas Reinhard. "Treatment of Adenoviral Keratoconjunctivitis." Essentials in Ophthalmology Cornea and External Eye Disease (n.d.): 163-72. Web. • Jacobs, Deborah S., Jonathan Trobe, and Janet L. Wilterdink. "Evaluation of the Red Eye." UpToDate. Wolters Kluwer, 24 Feb. 2016. Web. 4 Oct. 2016. • Keratitis. Perf. Paul Bolin. Keratitis. CRASH! Medical Review Series, 21 Nov. 2015. Web. 4 Oct. 2016. • Shah, Sushmita G., and Dikhil S. Gokhale. "Instruction Manual for Preparation of Fortified Antimicrobial Eye Drops." Bombay Ophthalmologists' Association, n.d. Web. 4 Oct. 2016. • Sugar, Alan. "Herpes Simplex Keratitis." Ed. Jonathan Trobe and Jennifer Mitty. UpToDate. Wolters Kluwer, 17 Aug. 2016. Web. 4 Oct. 2016. • Thompson, Andrew M. "Ocular Toxicity of Fluoroquinolones." Clinical & Experimental Ophthalmology Clin Exp Ophthalmol 35.6 (2007): 566-77. Web.
  30. 30. QUESTIONS?T H A N K Y O U F O R Y O U R T I M E A N D A T T E N T I O N !

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