Microsoft powerpoint - ant_seg_inter_grand_runds_rce_allergy_fuchs

Case History
• 58 y.o. female
• CC: “red painful eye”
• Tearing
• F.B. Sensation
Additional testing:
87% of all RCE occurs in
what part of the cornea?
• Reidy JJ, Pauli MP et al. Cornea 2000 •Recurrent Erosion
Syndrome
• Daytime meds?
• What about hyperosmotic
• Artificial tears PRN
• What medications should be
avoided?
• Bland Artificial Tear
– Doxycycline 100 mg bid x 2 months Ointments
– Dursun D. et al. Treatment of recalcitrant recurrent corneal erosions with inhibitors of • Eke T et al Recurrent symptoms following
matrix metalloproteinase-9 doxycycline and traumatic corneal abrasion Eye 1999 June
Options for Recalcitrant Cases:
• Metalloproteinases which cleave
Bowman’s layer below the
anchoring system
(Hemidesmisones)
• Develop through the production
of Leukotrienes
• James Reidy et al. Recurrent erosions of • The remainder had trauma induced causes dystrophy or epithelial basement membrane • 34 y.o. male - professional golf instructor • CC: Burning and can’t go outside because • Periorbital redness, dry skin and crusting • Corneal neovascularization superiorly approx. • People think I have pink-eye and stay away • Has been going on for “years” just much worse • Up to 30% of the US population suffer from some Allergic Eye Disease
• Allergies are the 6th leading cause of chronic • 3.5 Million lost work days each year• Over $6 Billion spent on prescription medications • An immune response to naturally occurring _______________________________• All Type I hypersensitivity reactions • Conjunctivitis may be cicatrizing (scarring, • Swollen eczematous periorbital skin• Superficial punctate keratitis• Superficial corneal infiltrates• Keratoconus• Anterior polar cataracts • Strong family history of Atopic disease (eczema etc.) • Persistent state of mast cells• High concentration of eosinophils• Lymphocyte activation • Chronic Redness, Itching and irritation • Mast cell stabilizers (Alocril, Alamast) • New site-specific steroids (Loteprednol 0.5%) – Blepharitis– Keratoconjunctivitis Sicca– Atopic dermatitis– Eczema of eyelids and periorbital tissue– Ocular allergic response • P.O. Doxycycline 100mg bid x 2-4 weeks – Perhaps after inflammation is under control • 1% hydrocortisone cream after a non-drying • Mast cells play a significant role in multiple • P.O. Antihistamines (Claritin, Allegra, • Protect with topical antibiotics (Quixin, – __________________________– __________________________ – Avoid highly preserved antibiotics (BAK, – Another visually threatening type of the allergic eye • Vascularization present?• Pulsed Steroid Drops (Alrex or Lotemax) • Presents in early spring - lasts until fall • Increased levels of superficial Mast Cells, • Intense itching• Tearing• Hot, tight, sensitive feeling to eyes• Photophobia* Eosinophil levels are not increased in patients with • Th2 cells• H1 and H2 activitation (extreme itching - H1)• Chronic in nature • Severe itching in young patients leads to severe • Steroid drops - pulsed to control inflammation • Associated with contact lenses, ocular prosthetics, • Lotemax (or Pred Forte in severe cases) exposed sutures, cyanoacrylate adhesive, extruded scleral buckles and ocular FBs • Restasis bid - very effective for shield ulcers • Lid discomfort upon lens removal• Increased lens movement • Increased lymphocytes and inflammatory components (cytokines, leukotrienes, prostaglandins) • Early Diagnosis is critical to rapid treatment • Discontinue offending agent (contact lens) for 1-3 • When returning to CL wear consider a different edge • Higher incidence at certain times of the • Perennial allergic conjunctivitis (PAC) – All year– e.g. animal dander, dust,– Indoor allergies • Also burning & tearing• Bilateral – Seasonal Allergic Conjunctivitis every year, – Newer mast stabilizers may only require 4-7 – Patients are not accustomed to seeing a • Best medication for anticipating seasonal – ACUTE Seasonal Allergic Conjunctivitis • Mast-cell stabilizers b.i.d. 1-2 weeks and • Treatment decision depends on signs & • Stimulation of the H1 receptor - ______________ • Stimulation of the H2 receptor - ______________ • Crosslinking of membrane bound IgE molecules • moderate to severe erythema and edema • Release and metabolism of arachidonic acid • “Affecting daily activities or lifestyle” – Alrex 0.2% (perhaps Lotemax 0.5% in severe • M. Abelson• 66 patients on Loteprednol 0.5% for 35 days for • Percentage of patients with an increase in IOP? • Increased Susceptibility to Infections • Loteprednol Etabonte 0.2% used for Seasonal & Perennial • Administered under a University of South Florida College – No patient had worsening of all-ready existing – No reported secondary infectious disease • 159 pts had used loteprednol etabonate 0.2% for more than – No patient developed a clinically significant Ilyas, Slonim, Braswell, Favetta, Schulman. Eye & Contact Len, Vol. 30, No. 1, 2004 • Loteprednol etabonate 0.2% similar to • Ester Steroids are inactivated by naturally – Ketone steroids remain in anterior chamber and • Ketone Steroids are not inactivated and can influence IOP & cataract formation • Post breakdown, ketone metabolites are still active – Ketone group in prednisolone is replaced by an – Ester group causes the molecule to be hydrolyzed by tissue esterases to become an • Category III - Significant Systemic Involvement • Rhinitis, itchy throat, cough, sinus congestion• Add Oral medications to topical regimen • Consider consult with allergist depending on severity, • P.O. Claritin, Allegra or Clarinex qd• If sinus congestion is present: • Not recommended with ocular signs/symptoms • P.O. Claritin-D 24-hr or Allegra-D 24 hr - qd • Maintain or increase preservative-free artificial tears • Potentially the most effective treatment for • Poor systemic absorption - few side effects • Vision affected at what time of the day? • Loss of endothelial cells• May be secondary to other factors: – Cataract Surgery stain on compromised – Discoloration of cornea (“Beaten Bronze”) – AC IOL’s (Pseudophakic Bollous Keratopathy) • Eliminate corneal sutures• Eliminate corneal surface incisions – Faster wound healing– Smoother topography– Stronger and more stable eye.
• Remove only diseased endothelium vs. • Creates a deep lamellar corneal pocket• No surface incisions or sutures! • Excise 7.5 - 8.0 mm of diseased tissue • Replace with healthy donor endothelium • Only complication noted in any clinical • Pump function maintains as does natural • Patient has symptoms of blurred vision in • Failed cornea after phaco in first eye

Source: http://www.dcos.org/images/Ant_Seg_Inter_Grand_Rounds.pdf