Case Analysis I- Lecture 4 Liana Al-Labadi, O.D. Case Analysis I- Lecture 4

If you hear hoof beats, think horses—not zebras This phrase sums up the philosophy that it is generally more productive to look for common rather than exotic causes for disease

Case 4: The Irritated Eye 19yo PM c/o red irritating eyes Frequency: Constantly (all the time, everyday) Onset: 1 month ago Location: Both eyes Duration: 6 months ago had a similar problem and was given eye drops which made things better Associated Factors: Any tearing? Any Discharge? YES- Notices yellow discharge once in a while Any Itch? YES- my eyes itch all the time and I’m always rubbing them Any burning sensation? Yes Are your eyes sticky? Crusty? Watery? Not sure they’re just extremely irritating Have you been sick lately? No Any pain? No- more irritation than pain Do you feel your eyes have become more sensitive to light? Yes Do you think anything has triggered this? Not sure Has you vision been affected at all? No my vision is fine Are you a CL wearer? No Relief: Tried using AT but not noticing any improvement Severity: 8/10 itch & irritation

DIFFERENTIAL DIAGNOSIS????

Case 4: The Irritated Eye POH: Negative for HA, DIPL, asthenopia, surgery, trauma, pain, F&F 6 months ago was diagnosed with some allergy condition of the eye LEE: 6 months ago by Dr. Mazen Khowaira FOH: Negative for AMD, DR, Glc, Cat LPE: Never had one PMH: Negative for DM, HTN, Cancer, Neuro FMH: Negative for DM, HTN, Cancer, Neuro MED: None Allg: NKDA; No seasonal allergies SH: playing sports; No known exposure to anyone with infectious eye disease Occupation: Student No alcohol consumption Smokes Argeeleh occasionally

Entrance Testing????

Case 4: The Irritated Eye Entrance Testing: DVA (s): 20/20 OD; 20/20 OS Motility: S&F OD, OS Confrontations: Full OD, OS Pupils: 4mm/4mm RRL OD, OS; No APD Minimal light sensitivity noted No pain on eye movement No DIPL No PAN

Additional Testing????

Case 4: The Irritated Eye SLE: L/L: Trace papillary reaction OD, OS No mucous debris OD, OS Conj: Tr-1+ temporal para-limbal injection OD,OS Small temporal calcified concretions/infiltrates OD,OS K: Clear OD, OS Iris: Flat & brown OD, OS AC: No cell & no flare/ D&Q OD, OS Lens: Clear OD, OS (undilated) IOP: ????

Case 4: The Irritated Eye http://mednt.jp/index.php/trantas+dots http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Vernal-Keratoconjunctivitis.html

DIFFERENTIAL DIAGNOSIS????

Case 4: The Irritated Eye Differential Diagnosis: Atopic keratoconjunctivitis Seasonal allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Chlamydial and Gonococcal conjunctivitis Superior Limbic Keratoconjunctivitis (SLK of Theodore) Toxic conjunctivitis Giant papillary conjunctivitis (associated with foreign body or CL wear or chronic inflammation) Episcleritis or Scleritis Pterygium Phylctenulosis

ADDITIONAL TESTS???

FINAL DIAGNOSIS

Case 4: The Irritated Eye Assessment: Vernal Keratoconjunctivits (VKC) OU Plan: Begin FML ophthalmic solution QID OU x 1 week then BIDx 1 week then stop Recommend Cool Compresses OU Recommen Genteal ATs PRN OU RTC in 2 weeks for F/U At F/U consider Patnol BID OU

VKC Major Symptoms: Minor Symptoms: Ocular itching- usually severe Ocular burning Photophobia Tearing Redness Thick, ropy discharge Seasonal (spring/summer recurrences) History of atopy- (asthma, rhinitis, and eczema)

VKC An allergy associated recurrent inflammatory disease Usually bilateral though asymmetry is common Two forms exist: Tarsal VKC Limbal VKC (less common) Epidemiology: <1% of population Males > Females Usually seen in young boys Most common 5-20 years of age Most common in the springtime (correlating to allergen levels) Numerous flare-ups during childhood Predilection for warm/dry climates

VKC Pathogenesis: The immunopathogenesis is multifactorial. Classically it has been thought of as a type I IgE-mediated hypersensitivity reaction It has been suggested that there is cell-mediated Th-2 involvement.

VKC Tarsal VKC Signs: Limbal VKC Signs: Large conjunctival papillae under upper lid Apparent on lid eversion Usually results in pseudo-ptosis Limbal VKC Signs: Limbal & paralimbal conjunctival injection Broad, thickened conjunctivl nodules near the limbus with white lesions over top aka Horner-Trantas’ dots Usually there is a confluence of nodules Most commonly seen at the superior cornea-limbus margin Usually have a mild, milky-white gelatinous appearance Trantas’ dots= aggregates of eosinophils & degenerated epitheloid cells

Tarsal VKC http://webeye.ophth.uiowa.edu/eyeforum/cases/case70/Vernal-Keratoconjunctivitis-Atopic-Asthma_Fig1.jpg

Limbal VKC http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Vernal-Keratoconjunctivitis.html http://www.drmalcolmmckellar.co.nz/allergic-eye-disease/what-is-it.html

VKC Other Signs? Corneal involvement in 50% of the cases Punctate epithelial keratitis Superficial K pannus Corneal shield ulcers Well-delineated, sterile, gray-white infiltrate Observed in 10% of patients

VKC Complications: (in 6% of patients) Visual loss from: K vascularization K scars Keratoconus Steroid-induuced cataracts Steroid-induced glaucoma

VKC Treatment 4 weeks prior to allergy season begin topical treatment with: Mast cell stabilizer (i.e. cromolyn sodium 4% QID) Mast cell stabilizer/Antihistamine: i.e. olopatadine 0.1% BID OR lodoxamide 0.1% QID) Antahistamine: (i.e. azelastine 0.05% BID) If moderate to severe inflammation: Topical steroid (fluorometholone 0.1% to 0.25% OR lotepredonol 0.5% OR prednisolone acetate 1% OR dexamethesone 0.1% ointment) 4-6 times a day With the appropriate tapering scheduke Cool compresses If shield ulcer: Topical steroid +/- topical antibiotic and cycloplegic agent If not responding to treatment, consider cyclosporine 0.05% BID

VKC Follow-up schedule: Prognosis: Every 1-3 days in the presence of a shield ulcer Otherwise every 1-2 weeks Maintain anti-allergy drops for the duration of the season Patients on topical steroids should be monitored regularly Prognosis: Poor if increased size of papillae Poor if sever bulbar /limbal VKC