Marginal Ulcers or Peripheral Ulcerative Keratitis In this interactive module peripheral ulcerative keratitis will be reviewed This will be in the context of a diagnostic classification management algorithm and case presentations ID: 759272
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Slide1
Guillermo RochaW Bruce Jackson
Marginal Ulcers or
Peripheral Ulcerative Keratitis
Slide2In this interactive module, peripheral ulcerative keratitis will be reviewed. This will be in the context of a diagnostic classification, management algorithm and case presentations.
Learning Objectives
2
To better understand the various etiologies of corneal ulcers including Infectious vs. Non-Infectious and Systemic
vs
Local
Discuss the approach to diagnosis including dry eye testing, review of systems, cultures and systemic testing
Review management principles including wound healing, prevention of perforation and addressing the underlying condition
Slide3Crescent shaped, destructive inflammatory lesion affecting the juxtalimbal corneal tissueOften associated with systemic diseaseMay signify “vasculitis” and thus, be potentiallylife-threatening
Peripheral Ulcerative Keratitis (PUK)
3
Rowe JA, Barney NP. Principles and Practice of Cornea,
Ch
32; Copeland,
Afshari
, Eds.
Slide44
These are all PUK
–
How
do you manage them?
Slide5MARGINAL INFILTRATIVE / ULCERATIVE KERATITIS
5
Bacteria and Fungi
Viruses
Acanthamoeba
Systemic Autoimmune/
Inflammatory
Local Toxic
Infectious
Sterile
Etiology
Slide66
1
2
3
4
5
6
What would you use?
No
therapy
Antibiotics
Steroids
Antifungals
Antihistamines
Systemic
drugs
Slide7TWO CASES TO CONSIDER
7
Slide88
What would you do?
Slide9HistoryThe patientPrevious therapies
KNOW MORE ABOUT…
9
Slide1010
What would you do?
Slide11Enhance wound healingPrevent perforationAddress the underlying condition
MANAGEMENT PRINCIPLES
11
Slide12ETIOLOGIC CONSIDERATIONS
12
LOCAL
NON-INFECTIOUS
SYSTEMIC
NON-INFECTIOUS
LOCAL
INFECTIOUS
SYSTEMIC INFECTIOUS
Slide1313
Which is which?
LOCAL
NON-INFECTIOUS
LOCAL INFECTIOUS
Slide14SYSTEMIC NON-INFECTIOUSLOCAL INFECTIOUS
14
Which is which?
Slide15NON INFECTIOUS PERIPHERAL INFILTRATIVE KERATITIS
15
Stern GA. Cornea, Ch 23; Krachmer, Mannis, Holland, Eds.
Microulcerative
Macroulcerative
Slide16Generally manifestation of systemic, immune-mediated diseaseMost common: Rheumatoid arthritis, Wegener’s granulomatosis and polyarteritis nodosa
NON INFECTIOUS PERIPHERAL INFILTRATIVE KERATITIS
Stern GA. Cornea, Ch 23; Krachmer, Mannis, Holland, Eds.
16
Microulcerative
Macroulcerative
Punctate marginal keratitis
Peripheral keratitis associated with
blepharitis
Slide17NON INFECTIOUS PERIPHERAL INFILTRATIVE KERATITIS
17
Stern GA. Cornea, Ch 23; Krachmer, Mannis, Holland, Eds.
Microulcerative
Punctate marginal keratitis
Staphylococci, Streptococci,
Haemophilus
, hypersensitivity to medications
Peripheral keratitis associated with
blepharitis
Catarrhal ulceration
Phlyctenulosis
Peripheral rosacea keratitis
Slide18SizeNumberLocationIntervening space…not really, although:Catarrhal may have intervening space, and be located at the 2, 4, 8 and 10 o’clock positions
Are There Any Distinguishing Features?
18
Slide19PERIPHERAL CORNEAL INFLAMMATION
Stern GA. Cornea, Ch 23; Krachmer, Mannis, Holland, Eds.
19
INFECTIOUS
IMMUNOLOGIC
EPITHELIUM
Usually epithelial defect
Usually intact initially
DISCHARGE
Usually
Unlikely
INFILTRATES
Spread centrally
Spread concentrically
HYPOPYON
Common
Uncommon
Slide20Treat without testing?Treat, but testing required?
Which Ones Need to Be Worked Up?
20
LOCAL
NON-INFECTIOUS
SYSTEMIC
NON-INFECTIOUS
LOCAL
INFECTIOUS
SYSTEMIC INFECTIOUS
Slide21Avoid treating with topical steroids
HERPETIC ULCERS (HSV)
21
Slide22CONSIDER THE ROLE OF:
22
DRY EYE
TESTING
REVIEW OF SYSTEMS
CULTURES
SYSTEMIC
TESTING
Slide23Dry Eye QuestionnaireAssessment of lid marginsTear film breakup timeCorneal and conjunctival stainingTear osmolaritySchirmer testSerology: SSA, SSB, Rheumatoid Factor, ANA
DRY EYE TESTING
23
BACK TOSLIDE 78
BACK TO
SLIDE
97
Slide24BacterialViralFungalAcanthamoebaChalmydia
CULTURES
24
BACK TOSLIDE 78
BACK TO
SLIDE
97
Slide25Rule out those conditions associated with peripheral ulcerative keratitis
REVIEW OF SYSTEMS
25
BACK TOSLIDE 78
BACK TO
SLIDE
97
Slide26Complete blood countErythrocyte sedimentation rateC reactive proteinUrinalysisChest X-rayRenal function testsSyphilis, Hepatitis C
SYSTEMIC TESTING
26
BACK TOSLIDE 78
BACK TO
SLIDE
97
Slide27Rheumatoid factorAntinuclear antibodiesAntineutrophil cytoplasmic antibodies (ANCA)Tissue biopsyLung, kidney
SYSTEMIC TESTING
27
BACK TOSLIDE 78
BACK TO
SLIDE
97
Slide28MARGINAL INFILTRATE
28
When to culture?
When to use antibiotics?
When to add steroids?
Slide29ETIOLOGIC CONSIDERATIONS
29
LOCAL
NON-INFECTIOUS
Slide30ETIOLOGIC CONSIDERATIONS
30
Catarrhal infiltratesPhlyctenulosisAcne rosaceaPsoriasisContact lensesTopical anesthetic abuseToxicFood allergiesMooren’s ulcer (??)
LOCAL
NON-INFECTIOUS
Slide3131
Slide3232
Slide3333
Slide34ETIOLOGIC CONSIDERATIONS
34
LOCAL
INFECTIOUS
Slide35ETIOLOGIC CONSIDERATIONS
35
BacterialViralFungalAcanthamoeba
LOCAL
INFECTIOUS
Slide3636
Slide3737
Slide38One infiltrateLarger than 2mm in diameterLess than 3mm from the visual axisALWAYS CULTURE
1-2-3 RULE
38
Slide3939
Slide40History of contact lens wear or traumaNon resolvingRing infiltrateALWAYS CULTURECONSIDER CORNEAL BIOPSY
ALSO…
40
Slide41ETIOLOGIC CONSIDERATIONS
41
SYSTEMIC
INFECTIOUS
Slide42ETIOLOGIC CONSIDERATIONS
42
Herpes virusChlamydia
SYSTEMIC
INFECTIOUS
Slide4343
Slide4444
Slide45ETIOLOGIC CONSIDERATIONS
45
SYSTEMIC
NON-INFECTIOUS
Slide46ETIOLOGIC CONSIDERATIONS
46
Rheumatoid arthritisSLEDiscoid lupusSclerodermaRelapsing polychondritisCrohn’sUlcerative colitisPolyarteritis nodosaWegener’s granulomatosisChurg-StraussBenign hypergammaglobulinemic purpuraTemporal arteritis
SYSTEMIC
NON-INFECTIOUS
Slide4747
Slide4848
Slide4949
Slide5050
Slide5151
Slide5252
Slide5353
Slide5454
Slide5555
Slide5656
Slide5757
Slide5858
Slide5959
Slide6060
Slide61Enhance wound healingPrevent perforationAddress the underlying condition
MANAGEMENT PRINCIPLES
61
Slide6262
ENHANCE WOUND HEALING
Slide63Lid HygieneAntibiotic coverageLubrication: Preservative-freeAutologous serum drops
ENHANCE WOUND HEALING
63
Slide6464
PREVENT PERFORATION
Slide65Collagenase or collagenase synthetase inhibitors1% Medroxyprogesterone10-20% AcetylcysteineCyclosporine 0.05%DoxycyclineTissue adhesive, bandage CL, lamellar and tectonic grafts, amniotic membrane transplantCAUTION: topical steroids
PREVENT PERFORATION
65
Slide6666
ADDRESS THE UNDERLYING CONDITION
Slide67GlucocorticoidsIV pulse initiallyOralSystemic immunomodulatorsAntimetabolitesAlkylating agentsT cell inhibitorsBiologics
ADDRESS THE UNDERLYING CONDITION
67
Slide68GlucocorticoidsIV pulse initially: 1g per day, for 3 consecutive daysOral: 1mg/kg/day, not to exceed 60-80 mg/day
ADDRESS THE UNDERLYING CONDITION
68
Slide69Systemic immunomodulatorsAntimetabolites: MTX, AZT, Mycophenolate mofetil, LeflunomideAlkylating agents: CyclophosphamideT cell inhibitors: Cyclosporin ABiologics: Infliximab, etanercept, rituximab
ADDRESS THE UNDERLYING CONDITION
69
Slide70Back to Our Two Cases to Consider
70
Slide7171
What would you do?
Slide72HistoryThe patientPrevious therapies
KNOW MORE ABOUT…
72
Slide7362yoMOriginal presentation: conj cyst OD -marsupializationMGD = full Lid Hygiene, tea tree oil facewash, DoxycyclinePossible history of CRVO? Amblyopia?5 mo later: PUK
CASE HISTORY SH
73
Slide74CASE HISTORY SH
74
Slide75CASE HISTORY SH
75
Slide76CASE HISTORY SH
76
Slide77CASE HISTORY SH
77
Slide78What would you do?
78
Do you think this is Dry Eye/Ocular Surface related?
Do you think this is a local infection?
Do you think this is related to a systemic condition?
Do you think systemic testing is warranted?
Slide7962yoMOriginal presentation: conj cyst OD -marsupializationMGD = full Lid Hyg, TTO, DoxyPossible history of CRVO? Amblyopia?5 mo later: PUKPrednisolone acetate 1% tid –better 3 wks laterTests: all negative, except atypical ANCA
CASE HISTORY SH
79
Slide80CASE HISTORY SH: 3 WEEKS LATER
80
Slide81Worse again: 20/60New lesions superiorly and inferiorlyWhat would you do?
ONE MONTH LATER…
81
Slide82Enhance wound healingLid hygieneFucidic acid to lidsPrevent perforationPrednisolone acetate 1%Doxycycline 100mg PO qhsAddress the underlying conditionSystemic testing: Atypical ANCA (+)Referral to Internal Medicine
MANAGEMENT HISTORY
82
Slide83IMPROVED AND STABLE
83
Slide84IMPROVED AND STABLE
84
Slide85WHAT ABOUT ANCA?
85
Slide86Antineutrophil cytoplasmic antibodies are specific and sensitive markers for different forms of vasculitides
ANCA
86
Slide8787
Slide8851yoFGlaucoma on multiple medsChronic red eye OS 1-2 yrsIs this toxic? Stopped everythingSome improvement, but…4-5mo later, worse, gooey, leaky, on PatadayNow with PUKOD perfectly fine
CASE HISTORY FW
88
Slide89CASE HISTORY FW: 5MO
89
Slide90CASE HISTORY FW: 5MO
90
Slide91CASE HISTORY FW: 5MO
91
Slide92CASE HISTORY FW: 5MO
92
Slide93CASE HISTORY FW: 5MO
93
Slide94CASE HISTORY FW: 8MO
94
Slide95CASE HISTORY FW: 8MO
95
Slide96CASE HISTORY FW: 8MO
96
Slide97What would you do?
97
Do you think this is Dry Eye/Ocular Surface related?
Do you think this is a local infection?
Do you think this is related to a systemic condition?
Do you think systemic testing is warranted?
Slide9851yoFGlaucoma on multiple medsChronic red eye OS 1-2 yrsToxic? Stopped everything4-5mo later, worse, gooey, leaky, on PatadayPUKCultures:Dx Strep Anginosus, Eikenella corrodensSensitive to Ciprofloxacin –Improved!
CASE HISTORY FW
98
Slide99CASE HISTORY FW:Follow Up –on Ciprofloxacin gtt/ung
99
Slide100CASE HISTORY FW:Follow Up –on Ciprofloxacin gtt/ung
100
Slide101CASE HISTORY FW:Follow Up –on Ciprofloxacin gtt/ung
101
Slide102CASE HISTORY FW:Follow Up –on Ciprofloxacin gtt/ung
102
Slide103Worse again! Marked inflammation, PUK, discharge, corneal thinning and vascularizationExtreme photophobiaNO intraocular inflammation
BUT… 2 MO LATER
103
Slide104104
What would you do?
Slide105Enhance wound healingLid hygieneContinue with topical ciprofloxacinPrevent perforationIV Methylpredisolone 1g daily for 3 daysContinue with oral PrednisoneAddress the underlying conditionReferral to Internal Medicine: IMTImproved at last visit
MANAGEMENT HISTORY
105
Slide106LATEST FOLLOW-UP
106
Slide107LATEST FOLLOW-UP
107
Well controlled on oral Prednisone and Methotrexate
Slide108ETIOLOGIC CONSIDERATIONS
DIAGNOSTIC CONSIDERATIONS
MANAGEMENT PRINCIPLES
SUMMARY
108
Slide109ETIOLOGIC CONSIDERATIONS
109
LOCAL NON-INFECTIOUS
SYSTEMIC
NON-INFECTIOUS
LOCAL
INFECTIOUS
SYSTEMIC INFECTIOUS
Slide110DIAGNOSTIC CONSIDERATIONS:
110
DRY EYE
TESTING
REVIEW OF SYSTEMS
CULTURES
SYSTEMIC
TESTING
Slide111MANAGEMENT PRINCIPLES:
111
ENHANCE
WOUND HEALING
PREVENT PERFORATION
ADDRESS UNDERLYING CONDITION
REFER
AS NEEDED