Headaches in Primary Care Steve Cobb MD Residency Program Director ESJH Family Medicine Residency.
Josh Johnston, O.D., F.A.A.O. Clinical Director/Residency ... · PDF fileClinical...
Transcript of Josh Johnston, O.D., F.A.A.O. Clinical Director/Residency ... · PDF fileClinical...
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RedEyes:It'sJustConjunctivitis...OrIsIt?
JoshJohnston,O.D.,F.A.A.O.ClinicalDirector/ResidencyDirectorGeorgiaEyePartners
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* Alcon* Allergan* BioTissue* Shire* J&J* Founder-OculusConsultingPartners* ContributingEditor-OptometricManagement
Disclosures
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Optometry:PrimaryEyeCareProviders
Whosee’syourpatients?
* PCP’s* UrgentCare
* Pediatrician
* PA
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PracticeGrowthOpportunity
* Medicaleyeserviceshelpbringinpatients* Leadstoincreasedspectaclesales* Enhancescontactlenscare* Patientretention=increasedrevenue* Greaterwordofmouth(referrals)* Greateroverallgrowthinallareas(optical,medical,CL's)
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Cases
Wewillreviewcommonanduncommoncausesof“redeyes”commonlyseeninpracticeEtiology:* Infectious* Inflammatory* Immune* Idiopathic* Allergic* Environmental* Other
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“Common”RedEyes
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Episcleritisvs.Scleritis
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Scleritis
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MGD
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MGDandNewTreatmentOptions:BBL/IPL
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DemodexDiagnosis
* Lashepilation,examinelidmargin* Viewlashunderlightmicroscopetoconfirmmites
* Tx:Inofficeandhome* Incidenceofinfestationincreaseswithage* 84percentofthepopulationatage60* 100percentofthepopulationolderthan70yearsofage
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Conjunctivitis
Allergic?Bacterial?Viral?- OTCvsRX?- ATs- Coolcompress- Topicalsteroids- Nasalsprays- Oralmeds
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ChallengingCases
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* 23yearoldfemaleCaucasian* Recentlymarried(2014)* Symptoms:severeocularpainOS>OD,ocularhyperemia
OSx5daysandnowOD,lidswelling,rasharoundlids,scalp,andface* Sorethroat,febrile,earinfection,nasalcongestion* (+)Hxofvaricella-zosterasachild* (+)Hxofectodermaldysplasia* TakingBactrimPOandAugmentinPO
Case#1:TheNewBride
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* Vesiclesfromforeheadtochin* Bilateral* Eyelidsswollenshut
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* Getagoodlookatthecornea!* Thisphotowasthebettereye!
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* Cornealcultures• Sensitivity/Specificity?Cost?Efficient?
* Cornealsensitivity-cottonwisptest* Futurepointofcarediagnostics?Differential?
Testing
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Differential:
* Pseudodentrites-HZV* HSV-terminalendbulbs* Healingepidefect* Recurrenterosions* Acanthomoeba* Neurotropiccornea* CLwearer
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HSVTreatment
* Valtrex500MGTIDPO* Zirgan5x/dOU* D/CBactrim,continue
Augmentin* PolytrimQIDOU-
prophylaxis* CyclogylTIDOU* Tylenol#3PO* PCP-immunestatus?
TestingDone:* Slitlampphotos* Cornealcultures/scraping
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* OnlyworksoncellsinfectedwithHSV* ProdrugthatgetsphosphorylatedtoganciclovirtriphosphatebythymidinekinaseinhibitingDNApolymerase* Nontoxic* Lesssideeffects
Ganciclovir
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* Addphotos
ChronicDisease(3/16)
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HSVKeratitis:TypicalPresentation?
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HSV
* Swollenepithelialborders* Branchedlineardendriticulcerscontainactivevirus* Atypicalappearance:
-geographiculcer-largedendriticulcers-stromalkeratitis-disciform endotheliitis
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Case #2 72y/oAAF-1wkhx“shingles”c/odec.VaOS.Valtrex1gramTIDPO
Va:20/30OD,20/100OS
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HZO
• Valtrex1GramTIDPO
• Tobradexophungbid
• ConsidertopicalAbperiorbital
• DurezolBID/PFTID• Zirgan5/Day
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“Pseudo-dendrites”v.“Dendrites”
Pseudodendrites:Treebranchesw/oterminalendbulbs.
Dendrites:Treebrancheswithterminalendbulbs.
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Case#3
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* Diagnosis:HSVstromalkeratitis* TxwithZirgan5/day,Valtrex500mgTIDPO,PredForteTID* CTLwearer
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InfectiousKeratitis
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* Steroidinducedbacterialkeratitis* *****CTLwearer****** Presentedtouswithbacterialulcer* Tx:BesivanceQ1,PolytrimQID,PolysporinungQHS,* Afterculturescameback,switchedtofortifiedVancomycinwithBesivance
InfectiousKeratitis
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InfectiousKeratitis
* Prokeraleftinplaceuntilcompletelydissolved* Completelyhealedepithelium* Continueduseofvanco&BesivancewithProkera
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* 44yearoldcontactlenswearerpresented3/29/2015toanoutsideclinicwithblurredvisionandpainOS* DocumentedAssessment3/29:cornealabrasionwithoutevidenceofinfection* DocumentedPlan3/29:* PrednisoloneAcetate1%QID* Returnin10days
Case#4
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* 1weeklater,presentstoemergencydepartmentforasecondopinion-“myeyeseemsworse…”* ERdoctorspokewithcornealspecialist* ERdoc:“Itlooksprettybad”* Steroidsdiscontinuedandbesifloxacinq1hrinitiated* FollowupASAPinclinic
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* BCVA:LP* Extensivemucopurulentdischarge* 8.5mm‘soupy’cornealulcerextendingnearlytoinferiorlimbus* Irishemorrhage* Flatanteriorchamber* Seidel(+)
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• Gramstain:Gm-rodsoxidase+
• Cxconfirms:PseudomonasAeruginosa
• Perforatedcornealulcer-immediatePKP
•
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* Besifloxacinq1hr* PolytrimQID* CiloxinointmentqHS* Oralciprofloxacin* PredForteQID* ProlensaqDay* CyclopentolateTID
Treatment
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Pseudomonas
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Pseudomonas
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Pseudomonas
* Rapid,extensiveinflammation* Eventualsurgicalintervention* Commoninhabitantofsoil,
waterandvegetation* Signs:Grayish-whiteinfiltratew/
anoverlyingepithelialdefect,veryinflamedeye,significantconjunctival,anteriorchamberreaction
* PseudomonaskeratitisisthemostcommonCTLrelatedinfection
* Symptoms:acuteonsetofsignificantpain,photophobia,decreasedVa
* Tx:BroadspectrumfluoroQ30,fortifiedGram-negativeantibiotics(e.g.,tobramycin/gentamycin)
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* Mostcommoncauseofinfectiouskeratitis* Red,painfuleye* Typicallysingleareaofulceration* Mayhavelidswelling,mucopurulentdischarge* Mosthaverapid(24to48hours)onset
BacterialKeratitis
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• Resistanceaseriousconcern-thinkMRSAwithnursinghome/hospital/healthcareexposure,immunosuppression,ornon-responsivetotreatment.
• Tx:BesivanceQ30• Considerpolytrimor
vancomycin.
StaphAureus
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* Immunemediatedprocessfromstaphfoundonlids* Mayhaveulcerationoversterileinfiltrates* Mayhavesecondaryinfectionofthisulceration* Treatment:antibioticointmentwithgrampositivecoverage+steroidtolidmargins+lidhygienew/hypochlorousacid* Tobramycin+dexamethasone* ConsiderMRSAriskfactors
StaphMarginalKeratitis
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Acanthamoeba
* Free-livingprotozoaActive:trophozoitesDormant:double-walledcysts—veryresistant
* Riskfactors:contactlenswear(80%),ocularexposuretouncholorinated/unsalinatedwaterespeciallyw/contactwear,trauma
* Extremepain,exquisitephotophobia,decreasedvision,injection
* Easilymistakenforbacterialorviral(firstsignoftendendritic),butwon’trespond
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Acanthamoeba
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* Patientpresentsearlywithirregular,disruptedepithelium* Punctateerosions* Pseudodendriteformation* Smallinfiltrates* Oftenmistakenforherpessimplex* Delayeddiagnosisistypical,avg.6weeks
Acanthamoeba
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* Painisdisproportionatetoclinicalpresentation* Radialperineuritis* Subepithelialinfiltratesalongradialcornealnerves
Acanthamoeba:EarlyStages
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* Ringinfiltrate* Seeninonly6%ofearlycases* Seeninonly16%oflatecases* Hypopyon* Progressivecornealthinning* Riskofperforation
Acanthamoeba:LateStages
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Acanthamoeba
* Latefinding:denseorringinfiltrate* Treatment
*Biguanide:PHMB0.02%everyhour*Diamide:Brolene0.1%(notcommonlyavailable)*Neomycinhassomebenefit(notmonotherapy)*Consideradjunctiveoralketoconazole* MayrequirePKP
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* Mayhavefeatherybordersorsatellitelesions……ormayresemblebacterial* Considerwithorganic-traumariskfactors,intact
epitheliumoverulcer,orminimaldischargecomparedtolesion* Timecourse,gramstain,andculturearekeyto
differentiate* Deeporscleralinvolvementisserious!* Treatment:natamycin(Fusarium)orvoriconazole(Candida)
* Longdurationoftreatment
FungalKeratitis
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* Broadspectruminitialcoverage:Moxifloxacin,Besifloxacin,orGatifloxacinq1-2hrswhileawake
* Broadspectruminitial/advancedcoverage:Fortifiedvancomycin(25mg/mL)+fortifiedtobramycin(14mg/mL),potentiallyplusafluoroquinolone
* Culturewhenappropriate,agentscustomizedtotheorganismandit’ssensitivities
* Fungalwillrequireantifungalagent;typicallyslow-growingsoinitialantibacterialtreatmentinanunclearcaseisreasonable
* Acanthomoebarequiresspecializedagentsandearlydifferentiationmakesabigdifferenceinoutcomes
KeratitisGeneralRecommendations
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* Cycloplegia(especiallyif+ACreactiontoreducesynechiae)* Bewareresistance.MRSAisontherise!Polytrimgood;
fortifiedvancomycinbetter.Pseudomonascanberesistanttofluoroquinolones;considerdouble-coverageifpoorlyresponsive.* Cornealabrasionsshouldbeprescribedantibioticsto
preventulceration* Withclosefollowup&appropriateantibiotics,may
considerbandagecontactlensesinabrasions* Donotpatchabrasionsincontactlenswearers,andbe
cautiouspatchinganyabrasion
KeratitisRecommendations
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Rare..UnlessIt’sInYourChair
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* 38Y/OAAFemale* BlurredvisionODX3years* SeverepainODX2weeks* DecreasedvisionODX2weeks* HxofPKPOSforacornealproblem* WastoldshewasunabletowearCLsorSrx
Case#5
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Case#5
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* ChronicdischargeinamOU* Admitsto“cleaning”eyesOU* PreviousdiagnosisofeyeinfectionOU* NoHxofCLwear* NoHxofcoldsores* Obese* (+)C-papuseQHS
Case#6
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Case#6
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* RetinalDetachments-Why?* DryEye* C-Papuse* Lagophthalmos/Microlagophthalmos* Pinguecula/pterygium* Systemic
Othercasues: