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Superficial punctate keratitis (SPK)
#1 Adenovirus
#2 Toxic staph response
#3 Eyedrop reaction
#4 Herpes simplex
#5 Herpes zoster
#6 SPK of Thygeson
#7 Veruccae
#8 Molluscum contagiosum
#1 Atopic conjunctivitis
#2 Superior limbic keratoconjunctivitis (SLK)
#3 Inclusion (Chlamydial) keratoconjunctivitis
#4 Vernal keratoconjunctivitis
#5 Trachoma
#1 Dry-eye syndrome
#2 Keratoconjunctivis sicca
#3 Exposure (Lagophthalmos and burns)
#1 Toxic staph reaction
#2 Triachisis
#3 Eyedrops
#4 Entropian
- SPK differential
- No conj or lid disease Thygesons
- Lid vesicles and no follicles Vaccinia
- No vesicles but follicles Adenovirus,
Chlamydia
- Vesicles and follicle's Herpes
simplex, Herpes zoster
- Small or peripheral infiltrate
- Hypersensitivity to staph or H. Flu toxin
- Sterile lesion
- Gray oval area near limbus with clear limbal area between
- Pain and photophobia
- Vascularization occurs later
Keratitis
- Marginal infiltrative keratitis
- Infiltration of polymorphonuclear leukocytes (PMNL) from limbus
into stroma
- Always a clear zone next to limbus - Interval of Vogt
- Necrosis of overlying epithelium leads to ulceration
- Often has leashes (Vessels pointing to infiltrate)
- Causes:
- Immune response to staph from lower lid
- Fine spk on inferior cornea in AM (Morning syndrome),
- Usually at 4:00 and 8:00
- Trapped toxins below CL produce PMNL response
- Hypersensitivity to solutions produce PMNL reaction
- Chronic hypoxia leads to edema which results in vasoactive
amine release which leads to PMNL response
- Superior (Under lid of SCL = Less 02)?
- See specific bacteria for treatment
- Penetrate cornea
- N. Gonorrhea
- Listeria
- Corynebacterium diphtheriae
- H. Flu
- Need a disrupted epithelium to penetrate
- Etiologies
-
- Trauma
- Tear film anomalies
- Corneal degeneration
- Neurotropic disorders
- Diabetes
- Immune disorders
- Steroid use
Acne rosacea
Blepharitis
Chalazions
Meibowmanitis
SPK
Pannus
- Avitaminosis A (Xerophthalmia)
Night blindness
Keratinization and thickening of cornea
Keratinization and thickening of conjunctiva (Bittots spots)
Ulceration and melting of cornea
Secondary to
KCS
RCE
SLK
Neuotrophic keratitis
- Keratoconjunctivitis Sicca
Decreased tear production
Sjogrens syndrome is dry eye, dry mouth and arthritis
SPK, decreased BUT
Dry irritated eyes
- Limbal vernal keratoconjunctivitis
- Psoriasis conjunctivitis
Mainly whites
More often females
Auspitz sign (Bleeding)
Arthritis
Itchy, burning eyes
Raised localized, superficial pink nodule on the conjunctiva (Infiltrate),
cornea or limbus
Lymphocytes
Type IV (Delayed) hypersensitivity
Injection which points to phylcentule ("Leash")
Itching, irritation, tearing, photophobia
Infectious keratatoconjunctivitis
- Acanthamoeba polyphagia keratitis
- Severe pain with mild anterior chamber reaction
- Apparent dendrite shape (Confused with Hepes S.)
- Edema
- Ring infiltrate is characteristic
- Ulcers
- Chemosis
- Adenopathy
- Protozoan
- Bacterial keratoconjunctivitis
- Most likely cause by age:
- 0-5 days Gonococcus
- 5 days-5 wk's Gonococcus, Chlamydia
- 5 wks-5 yrs Gonococcus,
Strept, H Flu
- 5 years + Gonococcus,
Staph
- Small papilla
- Tearing
- Mucopurulent,
- Foreign body sensation
- Lid edema
- Chemosis
- Papillary response
- Ulcer with dense infiltrate with indistinct borders
below epithelial defect with sharp borders
- Iritis
- Most ulcers central - Farthest from blood-borne immune system
Gram (+) cocci
Round or oval gray - white dry ulcers with distinct borders
Acute Conjunctivitis
- Most common
- Cornea clear
- Conjunctivitis inflamed
- Lashes matting with yellow - green discharge
- Palpebral Papillae (Reddish vascular tuft)
- SPK (Esp. at 4:00 and 8:00)
- Mild edema
- Erythema
- Lid crusting
- Staph Most common conjunctivitis
- Strept Most common conjunctivitis with URI
- H. flu Most common conjunctivis in kids
- Neisseria Most common hyperacute conjunctivitis
Chronic Conjunctivitis
- Lid disease
- Poorly controlled infection
- Rare bug
- Chlamydia (1/3 of chronic cojunctiviti)
- Staph Aureus
- Staph Conjunctivitis
Staph Keratitis
- Associated with blepharitis
- Inferior cornea SPK due to toxins
- Mucopurulence (Lids stuck in AM)
- Staph ulcer
Gray-white infiltrated central ulcer
Round or oval with distinct border
May have sterile hypopyon
GI bug can cause corneal ulcer in immune suppressed
Slow indolent ulcer in imunosuppressed
Infrequent cause of corneal infection
- Strep Pneumonia
- Strept Conjunctivitis
Petechial sub-conjunctival hemorrhages and upper respiratory infections
Strept keratitis
Hemorrhagic
Pseudomembranes
Mild mucopurulence
Associated pre-septal cellulitis
Associated dacryocystitis
Used to be very common cause of keratitis (50% carry in respiratory system)
Ulcer is gray - yellow creeping towards center of cornea
Often follows trauma but can penetrate cornea
Rapidly may progress to perforation
Strept ulcer
Usually begins 24-48 hours after corneal trauma
Gray ulcer that starts at truama spreads towards center of cornea
Shaggy, indistinct leading edge
Commonly has a marked hypopyon
Gram (-) Cocc
Profuse wet infiltrate that rapidly spreads to include entire corneas;
Often sever lid reactions
Most common cause of hyperacute conjunctivitis.
N. meningitidis less common cause (Healthy carrier that has recovered from
disease)(Found in nose) (Pneumonia)
Can penetrate cornea
Ulceration, perforation, endophthalmitis
Takes 12-24 hours
Venereal signs
Rapid proliferation with copious discharge (Ballooning Lid)
Wear gloves and goggles during examination
Gonorrheae ulcer
Uncommon in USA
Yellow-gray ulcer that commonly perforates
Associated with hyperacute conjunctivitis
Gram (-) Bacillus
Diaper-itis
Entrobactor
Can penetrate cornea
Medical history (URI, ottis)
Children
Often purplish cellulitis
Lasts 9-12 days
Heavy mucopurulence
- Hemophillus keratoconjunctivitis
- Klebsiella
- Moraxella
Moraxilla keratoconjunctivitis
Diffuse SPK
Follicles
Mucopurulent
Maceration of canthi (Angular conjunctivitis)
Gray-white anterior stroma
Dense ulcer and hypopyon in alcoholic
May be painless
Slow to heal
Intense keratitis
Dense stromal infiltrate and occasional ring abcess
Most common cause of ulcer
Fastest advancing (Infiltrate visable 6-8 hours after trauma)
Follows injury (Can not penetrate)
Begins centrally as a gray infiltrate below epithelial defect with hazy cornea (Edema)
Yellow - green discharge that clings to ulcer and fluoresces
Yellow green discharge
May have ring abscesses (Antibody - Antigen reaction)
Sever anterior reaction and hypopyon
Corneal perforation in 2-5 days
Extended 3.5% risk
Daily wear 0.5% risk
Large yellow or gray infiltrate beneath epithelial defect
Fusarium, Candida, Aspergilla, Cephalosporin
Rare to attack a health cornea
May follow trauma, steroids, suppressed immunity
Dirty gray infiltrate with irregular edges (Feathered)
Occasional hypopyon
Dry, rough texture
Usually peripheral cornea
Serpiginous (Creeping)
Coxsackie
Paramyxovirus Newcastles
Picornavirus Acute hemorrhagic conj. (Apollo II disease)
Rubella German measles
Rubeola Measles
Young healthy kids
Comparable to tonsilitis
- Acute follicular conjunctivitis
Adenoviral conjunctivitis
Droplet transmission
Usually in kids age 5-15
URI
5-12 day incubation
3-5 days very mild
Virus spreads across all of conjunctiva not mainly in fornix as bacteria
do
Vascular dilation and permeability to bring in white blood cells
Chemosis and injection
Some red blood cells also leak (Pinpoint petechia)
Lymphocyte production increases leading to adenopathy
Lymphocyte maturation with lid leads to follicles
Increased tearing and AM mucous on lids
Excess mucous and cells can attach to conjunctiva and form pseudomembranes
Viral damage to epithelial leads to SPK staining
Two weeks later lymphocytes migrate from limbus creating infiltrates
Inferior lid follicles, mild tearing, mild SPK
Pharyngitis, fever, maybe gastrointestinal upset
Cool compress 5-10 min 5 times/day
Vasoconstrictor tid (Decreaes swelling and increases comfort)
No steroids unless subepithelial infiltrates threaten acuity
Chronic follicular conjunctivitis
- Chlamydial keratoconjunctivitis.
- Trachoma
Worlds leading cause of blindness
Vector is flies drinking tears
Chronic follicular conjunctivitis
Upper tarsus has follicles and papilla
Thygesons keratoconjunctivitis may be mild forms of trachoma
Stage1 (Incipient)
Immature follicles on superior tarsus
Diffuse SPK
Superior pannus
Stage 2 (Established)
Follicles on superior tarsus
Limbal follicles
Stage 2B
Papilla obscure follicles
Follicles become necrotic
Stage 3 (Cicatrizing)
Follicles scarred
Entropia and trichiasis
Grossly visable pannus
Bacterial co-infections
Stage 4 (Healed)
Upper tarsus completely scarred
Blindness
- Neonatal chlamydia
- 5-12 days after birth
- Papillary reaction only (Lymphoid tissue not mature enough
to create follicles)
- Adult inclusion conjunctivitis
"Swimming pool conjunctivitis"
Follicle reaction more acute in inferior cul-de-sac
Papillary reaction more acute in upper lid
SPK
Mucopurulent discharge
No upper respiratory infection or fever for more than 2 weeks
Sexually active with new partner
Keratitis
Infiltrate
EKC-like opacities
Pannus
Sometimes iritis (Reiters syndrome ?)
May have male nonspecific urethritis or female chronic discharge
2-4 week history
Foreign body sensation
Mucopurulent discharge
- Toxic follicular conjunctivitis
Molluscum or verruca nodules on lids
Old medications (Pilo, Carbochol, Echothiophate, Epinephrine)
Eye make-up
Moraxella
Bacteria but may have follicles
Spontaneous remission in weeks or months
"Farmers lung" (From hay or vegtables)
"Mushroom worker's lung" (Moldy compost)
Bagassosis (Moldy sugar beets)
Fever, chills, cough, wheezing
Airborne fungus in SW USA
Inhaled
60% Asymptomatic
40% fever, myalgia, hilar adenopathy
2% develop chronic pneumonia
"Valley Fever" is primary infection with arthritis and erythema nodosa
Chlamydia
Epstein-Barr virus (herpes)
Young patients
Fever, malaise, headach, sore throat, lymphadenopathy
Acute phase lasts 1-3 weeks
Headaches, myalagia 2-3 weeks after exposure
Parotitis
Emididymo-orchitis in 25% of post puberty males
Vaccination (Measeles, Mumps, Rubella) at 15 months
- Parinauds ("Cat scratch disease")
Follows cat scratch, or licking
Organism lives in soil
Farm workers, botanists
Ulcerating nodules on extremities
Unknown cause
Granolomatous disease of lungs
Malaise, cough
Remits over months to years
Steroid used in severe cases
Primary = Chancre, lymphadenopathy
Secondary = Rash, headache, lymphadenopathy
Late = Neurosyphilis,
tabes dorsalis, sensory loss
- Tularemia ("Rabbit fever")
Follows contact with small wild animals
Most common vector in summer is ticks, flies
Most common vector in winter is rabbits
Fever, chills, malaise
Mycobacterium
Cough, weight loss, malaise
- Rubeola conjunctivitis
- Molluscum Cantagiosum
Smooth elevated nodule with an umbilicated central core
May shed cells and toxins onto conjunctiva
RX1 = Expression, excision, cryotherapy
Chicken Pox
Fever, malaise, sore throat
Lasts 2 weeks
Red punched out lesions
Occasional conjunctival vessicles, dendrite, uveitis
- Herpes Zoster ("Shingles")
Headache, malaise, fever, chills
Painful neuralgia
Eye signs if effecting the ophthalmic branch of the V cranial nerve
Corneal ulcer
Disciform keratitis
Interstitial keratitis
Sub-epithelial infiltrates
Decreased corneal sensitivity
Herpes Zoster conjunctivitis
Remains in trigeminal ganglion
Lymphadenopathy
Pseudomembranes
SPK
May have raised micro-dendrite with tapered endings that stains with rose-bengal
Begins a few days after rash and lasts 4-6 days
Corneal hypothesia like herpes simplex
"Hutchinson sign" on nose
Severe pain
Topical antiviral Viroptic no benefit for zoster
- Epidemic keratoconjunctivitis. (EKC)
Very common
Adenovirus, like PCF
Usually older than 15
No URI
Purple - pink bulbar conjunctiva
Tearing
Inferior lid follicles
Adenopathy
Pseudomembranes
50% have infiltrates
No sore throat or fever
Adenovirus 8 most often
Newer versions more virulent, May be sever in 3-5 days
Highly contagious first 7-14 days
First 8 days
Mild burning
Photophobia
Follicles
Lymph nodes swollen
Coarse SPK
By Day 6
Elevated focal epithelial lesions that stain
Marked foreign body sensation
Sub-epithelial opacities form under lesions
Second 8 days
Sever burning
Photophobia
Blurring
Third week
Multiple infiltrates in pupillary zone, first epithelial and later stromal
Gradually improves
Epithelial lesion fades by 30 days
Opacities may linger 2 years
More virulent forms sever in 3-5 days
Papilloma virus
If at lid margin, can shed cells and toxins
RX1 = Cautery or excision
- Pharyngo-conjunctival fever (PCF)
Beals swimming pool conjunctivitis
Most common in kids
No corneal signs
Injected
Foreign body sensation
Sore throat
Swollen non-tender preauricular node
Purple - pink bulbar conjunctiva
Hyperemia
Tearing
Follicles
Fever
Sore throat
Unilateral onset with other eye involved in a few days
Cornea rarely affected, some times have infiltrates
Most often age 5-15
History of a cold or a swimming pool
5-12 day incubation
Lasts 7-15 days
Lymphadenopathy
Adenovirus 3,4,7 (Beals)
General
Most common human virus
Leading cause of USA blindness due to infection
HSVI oral and facia
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