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

2. 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

3. 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

4. DIFFERENTIAL DIAGNOSIS????

5. 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

6. Entrance Testing????

7. 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

8. Additional Testing????

9. 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:
????

10. Case 4: The Irritated Eye

11. DIFFERENTIAL DIAGNOSIS????

12. 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

13. ADDITIONAL TESTS???

14. FINAL DIAGNOSIS

15. 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

16. 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)

17. 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

18. 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.

19. 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

20. Tarsal VKC

21. Limbal VKC

22. 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

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

24. 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

25. 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