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                         TMOD: THE MOST IMPORTANT CONDITIONS AND DRUGS

        Instead of memorizing long lists of side and adverse effects, some find it easier to categorize drug and
other therapies into absolute and relative contraindications given each patient’s history and exam findings.
Examples of this include:
        Non-selective topical beta-blockers (like Timolol) are absolutely contraindicated in patients with
            pulmonary disease, but relatively contraindicated in patients with cardiovascular disease.
        Topical sympathomimetics are absolutely contraindicated in patients taking MAO inhibitors (i.e., Nardil),
            but relatively contraindicated in patients with narrow angles or with symptoms of retinal detachment

Other specific adverse effects or contraindications that have historically been on the test include:
        a. Topical epinephrine can cause cystoid macular edema in aphakes or pseudophakes
        b. Topical miotics (especially echothiophate) can cause iris cysts
        c. Antipsychotics (phenothiozines, CHLORPROMAZINE) can cause corneal deposits
        d. Patients with iris clip intraocular lenses should not be dilated


CHAPTER 3: CONDITIONS AND DRUGS REQUIRING THE MOST DETAILED KNOWLEDGE
This chapter contains the majority of topics presented on the TMOD examination.

ALLERGIC DERMATITIS
A 62 yo patient presents to your office complaining of swollen, itchy eyelids. She states that she has recently
changed her eye makeup. You notice flaky, dry, reddened eyelid skin. This condition is best treated with:
a.     hydrocortisone 1% cream*
b.     Naphcon-A drops
c.     Chlorpheniramine maleate pills
d.     Erythromycin ointment

Hints: whenever there is a description of itching, it usually signifies an allergy. The mainstay drug of allergy
treatment is a cortisteroid, in this case, simple over-the-counter HYDROCORTISONE cream. You will find that
many questions require treatments with over-the-counter medications or physical therapy measures (like hot or
cold compresses).

Diagnostic Features:
(immediate or delayed) itchy, red, swollen eyelids

Immediate Type (Type 1 or histamine-mediated hypersensitivity)
Occurs suddenly in minutes to hour. Hives, urticaria (itching), hayfever with patchy areas of erythema (redness)
that may be moist and weeping.

Treatment of Immediate Type:
1. Removal of sensitizing agent (cosmetics, eye drops) if possible.
2. Frequent cold compresses.
3. Oral antihistamine/decongestants (indicated for immediate, Type I only).
     Benadryl (25mg DIPHENHYDRAMINE, 60mg PSEUDOEPHEDERINE) 1 tab q6h to q4h.
     ChlorTrimeton (4mg CHLORPHENIRAMINE, 60mg PSEUDOEPHEDERINE) 1 tab q6h to q4h.
     Dimetane (4mg BROMPHENIRAMINE) causes less drowsiness than other antihistamines.

    Newer prescription antihistamines that cause less drowsiness than Benadryl or Chlortrimeton:
            Seldane (TERFENADINE) no longer being marketed, but was an extremely popular drug for
               many years)
            Hisminal (ASTENIZOLE)
            Claritin (LORATADINE)
            Zyrtec (CETIRIZINE)
            Allegra (FEXOFFENADINE)

        Contraindications of antihistamines:           Diabetes, hypertension, cardiovascular disease, thyroid
        disease, and narrow angle glaucoma.
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        Common adverse effects: drowsiness, reduced tear production

4. Topical Steroids
HYDROCORTISONE 0.5% - 1.0% (Cortaid, Demarest, Cortizone 5) apply to lids tid to qid; not to be used in
eyes. Use caution in darkly pigmented individuals, particularly with 1% as skin depigmentation can occur.
5. Systemic Steroids are reserved for severe cases.
   PREDNISONE (40-60mg qd for several days, then taper as symptoms improve).
   TRIAMCINOLONE (Kenalog) 40 mg for 1 injection
   METHYLPREDNISOLONE (DepoMedrol) 80mg for 1 injection
6. Follow-up: 1 week

Delayed Type (Type IV or cell-mediated hypersensitivity)
    Onset is slower (days usually) than the immediate type above.
    Often from drug allergies (including allergy to preservatives).
    Dry, erythematous, eczema-like scales and patches with intradermal (within the skin) swelling.
       (Contrast this description with the description of the immediate type response)

Treatment of Delayed Type ****
Same as immediate, except antihistamines are not effective. Topical steroids like non-prescription
HYDROCORTISONE cream are effective and are the first-choice selection. Systemic steroids are indicated in
severe cases. Hint: if the allergy takes a while to get going and/or is dry, don’t select antihistamine treatment.
Follow-up: 1 week.

**Topical antihistamines or decongestants have minimal effect on allergic dermatitis.

Note:
Don’t confuse allergic dermatitis with preseptal cellulitis, or hordeolum (see below). The primary features
differentiating allergic dermatitis from infection are itching, the absence of pain on palpation, and a history of
exposure to a chemical or medication.


SEBORRHEIC BLEPHARITIS
A 60 yo patient comes into the office complaining that he has had an irritation in his eyes, worse in the morning.
This has been occurring for the past year or so. Your examination shows mildly redden eyelid margins with a
greasy appearing eyelid and eyelash mattering. The least appropriate treatment would be:
a.      tetracycline 250mg qid po
b.      erythromycin ointment qhs
c.      TobraDex ointment qhs*
d.      lid scrubs qid

Hints: In this case, you must determine that the description represents a seborrheic blepharitis, indicated
through the greasy description. All of the above are appropriate initial treatment, except for c, as it contains a
steroid. This case of blepharitis was not described as very severe, so a steroid would not be your first choice in
starting therapy. All of the other choices, alone or in combination, would be appropriate.

Diagnostic Features:
    Greasy eyelash mattering
    marginal erythema
    variable symptoms of irriation that is worse in the morning; seen more in elderly
    exam reveals greasy sleeves at base of lashes
    considered a non-infectious inflammation.

Treatment:
1. Lid hygiene: lid scrubs bid, taper as patient symptoms allow for maintenance. Scrubs mechanically remove
    lash debris that is a stimulus to inflammation. Eye scrub, OcuClens and other products are now considered
    standard of care (instead of baby shampoo and water). Anti-dandruff scalp shampoo (for scalp and
    eyebrows) has dubious value, but is considered a treatment by some.
2. For persistent symptoms or severe presentations, consider treatment as bacterial blepharitis. Consider
    anti-staph ung qhs, oral TETRACYCLINE 250mg qid x 2 – 4 weeks.
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3.   Follow-up: 4 weeks or prn


BACTERIAL BLEPHARITIS
Which of the following medications would be the most appropriate for the treatment of routine bacterial
blepharitis:
a.      bacitracin ung*
b.      chloramphenicol ung
c.      tetracycline ung
d.      sulfacetamide ung
e.      Neosporin ung

Hints: BACITRACIN is effective in treating staph, which is the most common cause of bacterial blepharitis.
CHLORAMPHENICOL, while effective, should not be selected as an answer in almost any case because of the
risk of aplastic anemia (a possible fatal blood disorder). TETRACYCLINE is not very effective in treating staph
and Neosporin has a 10% risk of allergy to the NEOMYCIN it contains. SULFACETAMIDE, while an acceptable
choice, has less efficacy at treating staph than BACITRACIN. Therefore, this is a question where one must
know that staph is the most common cause of blepharitis and that BACITRACIN is more effective than
sulfacetamide in treating staph. In addition, ruling out the other answers helps in narrowing your choice.

Diagnostic Features:
(You need to know the words used to describe the appearance of bacterial blepharitis)
    Same as seborrheic blepharitis except symptoms and signs more pronounced.
    Dry lash, collarettes, sleeves (with/without ulceration), and scurf (Diagnosis of staph etiology)
    Serpiginous (s-shaped), irregular, thickened lid margins (tylosis), madarosis (loss of lashes), trichiasis
       (misdirected lashes) are all signs of chronicity

Treatment:
1. Warm compresses and lid scrubs as previously described.
2. Anti-biotic ointment effective against gram+ bacterial species or else a broad spectrum antibiotic ointment
   applied to lid margins qid (generally erythromycin or bacitracin).
3. Follow-up: 4 weeks or prn


TOPICAL ANTIBIOTIC OINTMENT PHARMACOLOGY

INDIVIDUAL AGENTS

1. BACITRACIN ung 500 units/mg
          Bacteriocidal, narrow spectrum, excellent for staph and most gram+ species;           little strep or
            gram- effectiveness.
          Contraindications/side effects: insignificant
          Comments: effective, safe, often-Rx’ed drug for blepharitis

2. CHLORAMPHENICOL (Chloroptic) ung 10mg/g, 1%
          Bacteriocidal; broad spectrum
          Contraindications and side effects:
                     Aplastic anemia (prolonged/intermittent use of topical/systemic)
                     Bone marrow depression
      Comments: works great, but no longer the standard of care drug except in extreme circumstances
      because of adverse effects; therefore don’t select it as any correct treatment on the test.

3. ERYTHROMYCIN (Ilotycin, Ak-Mycin) 5mg/g, 0.5%
         Bacteriostatic, bacteriocidal; broad spectrum, moderate staph effectiveness
         Contraindications and side effects: insignificant in topical forms
         Comments: safe, effective choice in ung for blepharitis, especially long-term usage. Effective
           for “angular” blepharitis 2 to Moraxella. Ineffective against Pseudomonas.

4. TETRACYCLINE (Achromycin, Aerosporin) 10mg/g, 1%
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              Bacteriostatic/bacteriocidal; broad-spectrum, moderate staph effectiveness.
              Contraindications/side effects: dermatitis and photosensitivity in topical and systemic forms.
               Contraindicated in pregnant/nursing women and children (under 8 – 12).
              Comments: side effects along with availability of more effective, bacteriocidal medicines have
               limited TETRACYCLINE as a drug of choice for Staph ocular surface disease. Ineffective
               against Pseudomonas.

AMINOGLYCOSIDES

1. GENTAMYCIN (Garamycin, Gentoptic), TOBRAMYCIN (Tobrex) 3mg/ml
          Bacteriocidal; broad spectrum, excellent staph effectiveness, poor strep effectiveness.
          Contraindications/side effects:    reported localized toxicity and allergic reactions, with
           TOBRAMYCIN, pupillary dilation and conjunctival parasthesia (abnormal sensations such as
           burning) with GENTAMYCIN. Safety of both has not been established in pregnant women.
           TOBRAMYCIN has been approved for use in children.
          Comments: probably overkill in most cases of blepharitis except for the most severe
           presentations. Effective for Moraxella “angular blepharitis.”


SULFONAMIDES

1. SULFACETAMIDE 10% (Bleph-10, Cetamide, Sodium Sulamyd)
         Bacteriostatic, narrow-spectrum with excellent strep and Hemophilus effectiveness; moderate to
           minimal effectiveness to anything else.
         Contraindications/side effects: 10% of population is hypersensitive (allergic) to the sulfas
           and sulfas lose effectiveness in the presence of mucopurulent discharge. These facts are
           important to know and remember.
         Comments: probably poor choice for staph blepharitis. With its relatively high sensitizing
           property, sulfa drugs in general are a poor first choice in nearly any type of ocular infection.

2. SULFISOXAZOLE 4% (Gantrasin)
   Similar properties to SULFACETAMIDE

COMBINATION ANTIBIOTIC OINTMENTS:

1. NEOSPORIN ointment contains:
      1) POLYMYXIN B 10,000unit/g:
            A very narrow spectrum, bacteriocidal drug with good effectiveness against many gram- bacteria
            including Pseudomonas, but little against gram+ bacteria. Insignificant contraindications and
            side effects.
      2) BACITRACIN 500unit/g:
            Bacteriocidal drug with a spectrum of action that includes primarily gram+ bacteria, as well as
            gonococci.
      3) NEOMYCIN 3.5mg/g:
            Broad spectrum, bacteriocidal aminoglycoside with moderate effectiveness against staph.
            Unfortunately, 10% of people are hypersensitive (allergic) to NEOMYCIN.

2. POLYSPORIN ointment contains:
      1) POLYMYXIN B (gram -)
      2) BACITRACIN (gram +)
      Comments: Polysporin is an excellent and safe choice that covers both gram+ and gram- bacterial
      species in indicated cases (SCL wearers, for instance). Given NEOMYCIN’s sensitizing nature and
      Polysporin’s broad coverage, there is little need to Rx the NEOMYCIN-containing drugs for blepharitis
      and other ocular surface infections.

MEIBOMIANITIS
A 7 yo patients presents to the office complaining of burning, irritated eyes. You note the presence of foamy,
whitish tears and reddened eyelid margins. Appropriate treatment for this patient would be:
a.       hot compresses and lid scrubs*
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b.      tetracycline ung
c.      doxycycline po

Hints: There are a couple of points to pay attention to in this question.      First, note that this is a child, age 7.
Then, note the description of foamy tears. While other conditions can         cause reddened eyelid margins, only
meibomianitis causes milky or foamy tears. The mainstay of treatment is       hot compresses and lid scrubs. Don’t
get fooled into selecting any of the tetracyclines (choices b and c).          Children shouldn’t be prescribed
tetracyclines.

Diagnostic Features:
       Chronic burning and irritated eyes.
       Eyelid margins are typically red and erythematous with milky froth.
       Presence of milia (white plugs). Signs of mild ocular surface inflammation often present. Etiology
           is the increased amount of solid fatty acids in Meibomian secretions causing congestion of the
           glands.

Treatment:
1. Hot compresses bid – qid
2. Lid massage bid – qid
If non-responsive or severe:
3. Consider lid expression in office – painful!
4. Add TETRACYCLINE 250mg po qid/ DOXYCYCLINE 100mg po bid x 10 – 30 days (suppresses the lipase
    activity of bacteria that may be a factor and reduces the amount of semi-solid fatty acid in Meibomian
    secretions).
    Adverse effects of systemic tetracyclines include (you ought to know all of these):
                      1) Diarrhea and stomach upset; tetracycline must be taken on empty stomach whereas
                          with doxycycline this doesn’t matter.
                      2) Skin photosensitivity and rash.
                      3) Pregnant women and children under 8 – 12 (TETRACYCLINE attaches to calcium in
                          teeth and bone causing discoloration and softening)
5. Add antibiotic/steroid combination ointment or suspension to lids tid x 2 – 3 weeks.
6. Follow – up: 4 weeks

EXTERNAL HORDEOLUM (STYE)
The patient in the previous question presents to the office several months later. Now, you notice a small, focal,
red lump on the right upper lid margin. The patient reports that the lump is painful to the touch. The appropriate
initial treatment is:
a.         hot compresses and lid scrubs*
b.         tetracycline ung
c.         doxycycline po
d.         cortisone cream topically

Hints: This is a question where you may try to second-guess your answer on the last question. Or, you may
again make the mistake of using TETRACYCLINE on a child or you can make the mistake of using the cortisone
to treat an infection. This case scenario is a classic description of a hordeolum or stye (if it had not been painful,
this would have been a chalazion). Again, hot compresses and lid scrubs would have been a treatment of
choice.

Diagnostic Features:
    Red, painful lump at the lash line, often in children.
    Infection/inflammation of Moll/Ziess gland of the eyelid.
    Often accompanied by blepharitis.
      Non-painful lid lumps are probably chalazia.

Treatment:
1. Hot compresses qid
2. Don’t Express (risk of bacterial sepsis (infection) to brain through the vascular system).
3. Add anti-staph antibiotic ung bid – tid (optional, depends on severity).
4. Lid hygiene as needed (scrubs) after initial inflammation subsides.
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5. Follow-up: prn unless not resolving in 4 weeks


INTERNAL HORDEOLUM
A 20 yo patient comes into your office complaining of lid pain. She states that her upper left lid has been swollen
and a little painful over the past few weeks and seems to be getting worse. You notice a small amount of
redness and swelling of the left upper lid, and the lid is painful to the touch. Upon lid eversion, you note
significant localized redness and swelling. The least appropriate treatment of this condition would be:
a.       hot compresses and lid scrubs
b.       tetracycline ung
c.       doxycycline po
d.       Pred-G gtts*

Hints: The difference between the internal and external hordeola is made with these last two questions. The
internal form is deeper in the tissue than the external form and is more likely to require systemic therapy (answer
c above). Even so, the mainstay of therapy of each type is warm compresses and lid scrubs.

Diagnostic Features:
    Large localized lid swelling with erythema and pain.
    Lump can point toward the internal or external surface of the lid.
    Usually a staph infection of a Meibomian gland (contrast this with the glands affected with the external
      hordeolum – Zeiss/Moll gland).
    Questions addressing internal hordeola are quite similar to external hordeola due to both being painful,
      localized lid lesions.

Treatment:
1. Hot compresses qid
2. Anti-staph gtts q4h and ung qhs
3. Consider adding oral anti-staph antibiotics such as CEPHALEXIN, ERYTHROMYCIN, is TETRACYCLINE if
   non-responsive, or if there is a risk of developing preseptal cellulitis. Since internal hordeola occur deeper in
   the lid tissue, and the risk of spread of the infection is greater (preseptal cellulitis risk) systemic treatment is
   more often required.
4. Follow-up: prn unless not resolving in 4 weeks
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CHALAZION
A 55 yo patient presents to the office complaining of a swollen lid. She states that the lid has been swollen for a
few months and is not painful. You notice localized lid swelling that feels like a small lump in the lid. Appropriate
treatment might include:
a.      injection of triamcinolone into the lesion*
b.      injection of vancomycin into the lesion
c.      tetracycline po
d.      erythromycin po

Hints: This question describes a chalazion as there is no pain associated with the lump. A painful lump is a
hordeolum (or stye). Chalazia do not respond to antibiotics (b/c they are sterile), but may respond to hot
compresses and lid scrubs (not one of the choices above), surgery, or injection of steroids into the lesion. See
below for the important contraindications to steroid injection.       TRIAMCINOLONE is a steroid while
VANCOMYCIN is an antibiotic.

Diagnostic Features:
    Localized, firm lid swelling without pain.
    Granulomatous (lump-forming) inflammation of the Meibomian gland.
    Variable size, rate of growth.

Treatment:
1. Hot compresses, as often as long as possible and tolerable (bid – qid) x 2 – 3 wks.
2. Digital massage after compress.
3. If non-responsive, add 40mg, ml injection of steroid TRIAMCINOLONE (Kenalog) 1ml into and around
   chalazion.

    Contraindications:     steroid will depigment the skin in patients with darkly pigmented skin (ie African-
    Americans).

4. Surgical excision if conservative treatment is not effective.
5. Recurrent chalazia may indicate sebaceous gland carcinoma (or squamous cell carcinoma)! Know
   this fact!!!!



PRECEPTAL CELLULITIS
A 25 yo patient presents complaining of a red, swollen left upper lid. He states that this has worsened over the
past week or so, and he has been bothered over the past month by a red, swollen lid lump that was painful.
Another doctor prescribed hot compresses and lid scrubs, which the patient states he is not doing very often.
You notice redness and swelling extending from the lid margin up to the frontal area that is quite diffuse. The
eye appears normal, with VA of 20/20. EOM versions are unrestricted and pupillary responses are normal.
Appropriate treatment would be:
a.     continue compresses and add cephalexin po*
b.     continue compresses and add gentamycin ung
c.     d/c lid scrubs and hot compresses and start gentamycin ung
d.     d/c lid scrubs and hot compresses and start tetracycline po

Hints: this is a question testing your ability to modify treatment. A patient is already being treated in some
manner and you are asked whether the treatment needs to be changed. In this case, you are asked to Rx a
treatment for a case of a hordeolum (stye) that has worsened and turned into preseptal cellulitis. The important
addition in treating preseptal cellulitis is a systemic (oral) antibiotic. Oral cephalosporins have historically been
the systemic medicines of choice in treating preseptal cellulitis, as they are generally safe, readily available and
effective against the most common organisms causing this type of infection.

Diagnostic Features:
    Diffuse, red, painful upper and lower lid without proptosis or EOM involvement.
    Often there is a history of internal hordeola, blepharitis, or trauma. If in a child, consider Hemophilus or
      strep as etiological agents.
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       VA is unaffected (orbital rim is used as a clinical guide in separating preseptal infection from orbital
        infection – if swelling extends past the rim, consider it orbital. This is a more serious situation. )
       Proptosis, EOM problems, an APD or VA reduction may indicate deeper orbital involvement.

Treatment:
1. Same treatment for internal hordeolum PLUS an oral anti-staph antibiotic for 7 – 10 days.
2. Tetanus toxoid if needed and history of trauma
3. Follow-up: daily until improvement noted
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PHARMACOLOGY OF ORAL ANTI-STAPH ANTIBIOTICS
Note: Learn the common dosages specified below.

Cephalosporins
1. CEPHALEXIN (Keflex) 250 – 500mg qid po
2. CEFACLOR (Ceclor) 250mg q8h po
3. CEFUROXAMINE (Ceftin) 250 – 500mg bid po
Broad spectrum (except Pseudomonas) and bacteriocidal. Variable cross-sensitivity with PENICILLIN, therefore
be cautious for pt with penicillin allergy.

Penicillins
1. CLOXACILLIN 250mg q6h (qid) po; PENICILLIN that is effective against staph
2. DICLOXACILLIN 125mg q6h; same features as CLOXACILLIN
3. AMOXICILLIN/ CLAVULANATE (Augementin) po. Indicated for mild cases in children.
Note: most PENICILLINS are not effective against staph.

Others
1. TRIMETHOPRIM / SULFAMETHOXAZOLE (Bacitracin) po. Remember that TRIMETHOPRIM is one of the
   components of ocular drop Polytrim. Bactrim is often substituted in patients with PENICILLIN allergy.

Substitutes
1. ERYTHROMYCIN 500mg qid po
        Adverse effects:
               a. gastrotoxicity, nausea, vomiting, and diarrhea
               b. hepatotoxicity: hepatitis
**When tetracycline is contraindicated, erythromycin is often a good substitute.

2. TETRACYCLINE 250mg qid po
      Adverse effects:
             a. Gastrotoxicity
             b. Phototoxicity (sunburn easily)
             c. liver toxicity (less than ERYTHROMYCIN)
             d. tooth and bone impairment, therefore, contraindicated in pregnant women and children
             e. nervous system: dizziness and tinitis (ringing in the ears)

3. DOXYCYCLINE 50mg/100mg bid
     Has the same antibacterial spectrum, mechanism of action and side effects as TETRACYCLINE but can
     be taken with food.



PEDICULOSIS (pthiariasis; lice)
The town that you work in has reported an increase in lice infestation in the children at the local elementary
school. An appropriate medication to have on hand for treating the children with this condition is:
a.      physostigmine ung 0.125%*
b.      TobraDex ung
c.      Maxitrol ung

Hints: While PHYSOSTIGMINE may not be used much as a lice treatment anymore because of its side effect of
pupillary miosis (with resulting vision reduction and headache) it may still be on the exam. In addition, it is the
best choice of the above ointment as the other ointment contain a steroid that is inappropriate in this condition.

Diagnostic Features:
    Moderate itching and irritation.
    Most common in kids.
    Eyelash base crusts with nits (eggs) and organisms (lice) seen on lashes with slit lamp.

Treatment:
1. Mechanical removal of nits and lice with forceps (good luck)!
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2. Use of non-toxic ung to lid margin bid x 10 days to “suffocate” organisms (MERMURIC OXIDE, Vaseline,
   Lacri-Lube).
3. ECHOTIOPHATE 0.125% (Phospholide Iodide) or PHYSOSTIGMINE 0.25% (Eserine) ointment bid used
   to be a common treatment, however, less used today because of side effects (toxicity, miosis, ciliary spasm).
4. RID or Kwell shampoo (OTC) to remove lice from all body hair (not for ocular use).
5. Follow-up: 7-10 days

DEMODECIDOSIS (Demodex, mites)
A 70 yo man presents to your office complaining of itchy eyes over the past 3 months that seems to be worse in
the morning. You find thickened eyelid margins without much lid redness or swelling. The least appropriate
therapy for this condition would be:
a.      hydrocortisone topical cream*
b.      lid scrubs
c.      bland ophthalmic ung
d.      gentamycin ung

Diagnostic Features:
    Mild to moderate lid itchiness most common in older population.
    Thickened, hardened lids (indurations) with pyramidal collarettes at lash base.
    The Demodex mites live in hair follicles and sebaceous glands and can usually only be visualized by
      epilating and microscopic examination of the lash base.

Treatment:
1. Lid scrubs bid, warm packs bid
2. MERCURIC OXIDE 1% antiseptic ung qhs
   Adverse effects: local rash, mercury poisoning with long-term use.
3. Vaseline qhs – lack of sterility may make ophthalmic lubricating ung a better choice (Lacri-Lube)
4. Topical antibiotic ung are sometimes used – may be overkill for this
5. Avoid ECHOTHIOPHATE / PHYSOSTIGMINE ung because of adverse effects, although some authorities
   still suggest it.
6. Follow-up: 7-10 days

HYPERACUTE BACTERIAL CONJUNCTIVITIS
A 10 yo patient presents to the office for evaluation of his eye that has gotten red over the past day. He is
having a great deal of sticky discharge from each eye, with the eyelids being stuck together this morning when
he woke up from sleeping. Your exam reveals small hemorrhages on the bulbar conjunctiva of each eye, with
edema of each eyelid. Palpebral conj exam reveals a mixed follicular/papillary response. The most appropriate
course of action would be:
a.      referral to a pediatrician*
b.      referral to an ophthalmologist
c.      sulfacedamide 10% gtts q2h
d.      TobraDex gtts q2h
e.      Tetracycline po

Hints: This is a case of hyper acute bacterial conjunctivitis (a child, significant discharge, bleeding of the
conjunctiva, rapid onset). As such, systemic (oral) treatment and a pediatric consultation are indicated. As with
most all of the questions calling for referral to another healthcare practitioner, referral to an ophthalmologist is
rarely the correct answer. While TETRACYCLINE is an oral therapy, again, this medication is contraindicated in
children. Although an ophthalmic antibiotic may be used in concert with systemic therapy, significant discharge
is a contraindication to topical sulfa-containing medications (answer c above). The steroid in TobraDex is not
appropriate in this case.
**Referral is a release and discharge of patient care. Consultation is a request for an opinion.

Diagnostic Features:
    Most often found in children or young adults.
    Typically bilateral, rapidly progressive red eyes with mild to moderate irritation.
    Copious mucopurulence with varying adnexal and corneal signs of inflammation (erythema, edema, or
      staining).
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       Bulbar petechiae (bleeding) and tarsal membrane/pseudomembranes often present.               Mixed
        follicular/papillary response, often with preauricular lymphadenopathy.
       Possible causative organisms: Staph, Streptococcus pneumoniae, Hemophilus influenzae, Neisseria
        gonorrhea, Pseudomonas, other less common gram- bacteria, i.e. E. coli, Serratia marcensans.

Treatment:
1. Mandatory gram stain, culture, and sensitivities
   a. Gram stain will quickly determine the morphological characteristics of bacteria
   b. Cytology (looking at the cells from scraping under the microscope) will hopefully immediately reveal the
       inflammatory cell type to indicate the general cause of the inflammation (bacteria vs. virus vs. allergy vs.
       other).
   c. Culture lid and lash specimen onto blood and chocolate agar (chocolate agar preferentially grows
       gonococcus). Cultures will reveal (in hours to days) a sufficient amount of bacteria, fungal, or viral
       species (if using viral media as well) to determine the causative organism more precisely.
   d. Sensitivities are used to determine the antibiotics effective against the identified organism.
2. Begin empirical (broad spectrum, best-guessed) therapy based on above testing
   a. topical gtts: TETRACYCLINE, GENTAMYCIN, OFLAXACIN, or CIPROFLOXACIN q2h.
   b. systemic therapeutic agents: (select one)
       i.      Keflex (CEPHALEXIN) 250mg – 500mg qid
       ii.     PENICILLIN G (0.6 – 5 million units injected intramuscularly qd).
       iii.    AMOXICILLIN, AMPICILLIN, CARBENICILLIN, and TICARCILLIN are effective against strep
               and Neisseria (but not staph) and have variable gram- effectiveness. Penicillins have significant
               hypersensitivity (15%) and are commonly cross sensitivity. Anaphylaxis is the allergic reaction
               of most concern. Note: drugs ending in suffix “-cillin” are probably related to the penicillin
               family.
       iv.     ERYTHROMYCIN 500mg qid (this is the adult dosage).
3. Refer to pediatric or internist for management of systemic infection such as otitis media (ear infection) or
   upper respiratory infection that may coexist and for the proper pediatric dosage of systemic treatment.
4. Follow-up: daily


ACUTE BACTERIAL CONJUNCTIVITIS
A 10 yo patient presents to the office for evaluation of his eye that has gotten red over the past few days. He is
having a great deal of sticky discharge from the eye, with the eyelids being stuck together this morning when he
woke up from sleeping. Your exam reveals a papillary tarsal conjunctival response. Treatment should include:
a.      referral to a pediatrician
b.      referral to an ophthalmologist
c.      tobramycin gtts qid*
c.      TobraDex gtts qid
d.      Tetracycline po

Hints: Note the difference between this question and the previous question. This is a case of run-of-the-mill
bacterial conjunctivitis. The onset is not as rapid, there is no swelling of the lids, and it’s just a papillary tarsal
response. In this case, the appropriate therapy would be some type of topical antibiotic and of the choices listed,
TOBRAMYCIN is the only one that is appropriate. In actuality, tobramycin may not be your first choice in a case
such as this (a better drug might be Polytrim), but none of the other choices are appropriate, so you have to pick
the best one. The steroid that is a component of TobraDex is not appropriate in this condition.

Diagnostic Features:
    Unilateral, red eye, gradually worsening over a few days.
    Minor irritation is typical as is mucopurulence (this term refers to a combination of mucous and pus) and
      mattering of the lashes and lids that is worse in the morning. Inflammatory papillae are present, with a
      minimal follicular response.

Treatment:
1. Topical broad-spectrum antibiotic drops qid for 7 – 10 days.
2. Warm compresses ad lib.
3. Lavage (rinse) prn to remove discharge.
4. Follow-up: every 1-2 days
                                                                                                          12



TOPICAL ANTIBIOTIC DROP PHARMACOLOGY

INDIVIDUAL AGENTS:

1. CHLORAMPHENICOL 5%
       Has the spectrum breadth and the adverse effects previously discussed.
       It is particularly effective against Hemophilus influenza (commonly referred as H. flu), a common
        cause of bacterial conjunctivitis in kids ages 2 – 6.
       Again, do not select this medication as a correct therapy.

2. GENTAMYCIN 0.3% and TOBRAMYCIN 0.3%
       Has the same spectrum and adverse effects as previously described.
       TOBRAMYCIN has slightly greater gram- effectiveness and therefore is probably preferred in
        contact lens patients in whom Pseudomonas must always be a consideration.

3. TETRACYCLINE 1%
       Has particular effectiveness against Chlamydia.
        Remember the contraindications.

FLUOROQUINOLONES:

1. NORFLOXACIN 0.3% (Chibroxin)
      Spectrum: broad, including Pseudomonas, and H. flu. Bactericidal.
      Adverse effects: minor surface toxicity

2. CIPROFLOXACIN 0.3% (Ciloxan)
   OFLOXACIN 0.3% (Ocuflox)
       Spectrum: Broad, including Pseudomonas
       Comments: These are excellent medications for the therapy of a variety of ocular infections. In
         particular, their use has revolutionized the therapy of corneal ulcers, and has supplanted fortified
         antibiotics for their therapy. There is some evidence that CILOXAN penetrates the corneal better
         than CIPROFLOXACIN.
       Adverse effects: corneal depositions in CIPROFLOXACIN.

SULFONAMIDES:

SULFACETAMIDE 10, 15, 30%
SULFISOXAZOLE 4% (Gantrasin)
    Spectrum, mechanism of action, contraindications and adverse effects previously discussed.
    Comments: Despite the many sulfa-containing products available in individual as well as combined
      forms with steroids (Blephamide, Vasocidin) and decongestants (Vasosulf), sulfonamides have limited
      usefulness in contemporary eye care for bacterial conjunctivitis except in its most mild form.

COMBINATION ANTIBIOTIC DROPS:
1. NEOMYCIN – POLYMYXIN B – GRAMACIDIN (Neosporin, Neocidin)
      Solution equivalent to Neosporin ointment with the pharmacology same as the ointment.
        GRAMACIDIN is substituted for BACITRACIN in the solution form.
      Comments: GRAMICIDIN is a less effective gram+ antibiotic than BACITRACIN, leaving the solution
        form of Neosporin less effective against staph while keeping all of the sensitizing features of
        NEOMYCIN.

2. TRIMETHROPRIM – POLYMYXIN B (Polytrim)
       Solution only.
       TRIMETHOPRIM has a mechanism similar to the sulfonamides.
       Systemically, TRIMETHOPRIM is used to therapy acute urinary tract infections.
        Polytrim is broad spectrum and bactericidal.
        Negligible side effects.
                                                                                                              13


          Safe, effective medicine for conjunctivitis that covers nearly every species and is especially favored
           by some for treating children.


ADULT INCLUSION CONJUNCTIVITIS (CHLAMYDIAL CONJUNCTIVITIS)
A patient presents to the office complaining of redness of both eyes for the past 3 months. His primary care
practitioner prescribed Maxitrol drops 2 months ago for this condition, but there has been no resolution. The
patient is a 25 yo sexually active man. Your exam shows swollen preauricular lymph nodes and the palpebral
conj shows both papillae and follicles. Appropriate therapy would be:
a) tetracyclin po 250mg qid*
b) prednisolone acetate 1% qid
c) cephalexin po
d) gentamycin drops

Hints: One of the clues in determining if a question concerns a chlamydial infection is that it has lasted for
months. Definitive therapy is oral TETRACYCLINE or AZITHROMYCIN since adult inclusion conjunctivitis is the
ocular manifestation of a systemic infection. Don’t get fooled into attempting to treat topically only the ocular
manifestation.

Diagnostic Features:
    Variable presentation.
    Chronic conjunctivitis with episodes of acute inflammation followed by resolution, with or without
      therapy, or else a constant sub acute conjunctivitis.
    History of exposure to venereal disease. May resent with urethritis.
    Mixed follicular/papillary tarsal response with an enlarged preauriculat (in front of ear) lymph node.

Treatment:
1. Lab tests to confirm Chlamydia infection:
        a. Conj cytology/ Giemsa stain to detect inclusion bodies or use an immunoflourescent antibody test.
        b. Urethral culture
2. Treat topically: TETRACYCLINE 1% or ERYTHROMYCIN 1% qid for 1 month.
3. Treat systemically:      TETRACYCLINE 250mg po for 1 mo., DOXYCYCLINE 100mg po bid,
    ERYTHROMYCIN 250mg po qid or a single dose of ZITHROMYCIN mg po (Zithromax).
4. Follow-up: 1-3 weeks based on severity
                                                                                                                     14


TRACHOMA
An additional form of ocular Chlamydial infection.

Diagnostic Features:
    Bilateral chronic follicular conjunctivitis with lid scarring (resulting trichiasis) and conj scarring (which
      results in severely dry eye).
    May lead to corneal scarring from constant irritation.
    Onset looks like bacterial conjunctivitis with the addition of a preauricular lymph node swelling.
      Superior epithelial keratitis, sub epithelial keratitis, pannus (corneal vascularization), superior follicles
      come later in the course of the disorder.
    Herbert’s Pits are depressions at the limbus, trachoma always more severe superiorly. Arlt’s line
      =scarring on the conj.

Treatment: Treat as above for inclusion conjunctivitis.

VIRAL CONJUNCTIVITIS
A 36 yo patient presents to the office complaining of redness in each eye with watering and mild irritation. You
notice a follicular conjunctiva response. Treatment would be most appropriately started with:
a) artificial tears*
b) cold compresses
c) lid scrubs
d) gentamycin gtts

Hints: Viral conjunctivitis presents as watery eyes with follicles and an enlarged preauricular node. Watering is
the key word that might clue you in to the presence of a viral infection. A keratitis with corneal sub epithelial
infiltrates can also be present. The above question is one in which an over-the-counter, seemingly trivial
treatment is the correct answer. Watch out for this type of question and be sure to read all the available info,
including each lettered answer.

Diagnostic Features:
    Unilateral or bilateral onset of red, watery eye with little irritation or else mild burning.
    Possible prior medical condition (usually an upper respiratory infection or “cold”).
    Follicles are present inferiorly and an enlarge preauricular lymph node.
    Visual acuity varies with blink.
    Causative organism is typically an adenovirus or less frequently viruses from rare sources such as bird
      droppings (Newcastle’s) or cats (Parinaud’s Oculoglandular Fever).
    Adenoviral disorders are self-limiting and the treatment is palliative only, that is, treating the symptoms
      of the disorder only, not curing it.

Treatment:
1. Warm compresses.
2. Lavage (rinsing), artificial tears ad lib, add vasoconstrictor/antihistamines if itchy.
3. Mild steroid gtts (e.g. FML) qid x 1 wk. Little proven value except to reduce visible signs and symptoms in
   more severe presentation.
4. Follow-up: 1-2 weeks

EPIDEMIC KERATOCONJUCTIVITIS (EKC)
A 36 yo pt presents to the office complaining of a red right eye that began the past week or so. Your exam
shows a follicular conjunctivitis, central sub epithelial infiltrates in the right cornea and a large preauricular node
that is a little painful to the touch. Visual acuity is reduced at 20/60 in the right eye and 20/20 in the left eye. The
best treatment to increase the patient’s VA would be:
a) Tobradex gtts*
b) tobramycin gtts
c) gentamycin gtts

Hints: Sub epithelial infiltrates and follicular conjunctivitis are classic for EKC. Reduced VA is another telltale
description of this disease. These cases are most commonly treated with an antibiotic/steroid combination drug
or a mild steroid alone to reduce the infiltrates and improve the vision. In questions where there is a choice
between the TOBRAMYCIN and GENTAMYCIN (although both are the wrong answers here), remember the
                                                                                                                  15


primary difference between the two is that TOBRAMYCIN covers gram negative bacteria (pseudomonas) better
than GENTAMYCIN.

Diagnostic Features:
    Depends on time of presentation.
    Unilateral, acute, watery, follicular conjunctivitis with a grossly enlarged preauricular node and variably
       reduced VA.
    Sub epithelial infiltrates (SEI) present around 1 week (8 Days) after the onset of the conjunctivitis.
    Treatment:
1. Emphasize hygiene (warn patient not to share towels).
2. Warm compress and ravage porn.
3. Topical steroid or antibiotic combo drop indicated if patient uncomfortable, VA reduced, or there is a large
   amount of inflammation with dense sub epithelial infiltrates. Certainly treat with steroid is a secondary iritic
   develops.
4. Avoid school or work while discharge and erythema present.
5. Follow-up: 1-2 weeks

Comment: Clinically, viral ocular surface disease often presents with a mixture of signs and symptoms that
occur in several diagnostic category. Considering the benign outcome of adenoviral infections (whether
conjunctiva or corneal) practitioners will often use a mild steroid or steroid/antibiotic combo to improve signs
or symptoms. There may also be benefit to using a topical antibiotic effectively against gram+ bacteria that are
thought by some to spread the virus in the superficial corneal. Topical antiviral medications are ineffective in this
condition.


HERPES SIMPLEX INFECTION
Overview:
Herpes Simplex infection can take on a variety of appearance. The primary infection occurs when the patient is
a child and does not commonly affect the eye. Later in life, direct ocular infections can be seen. It is these later
secondary manifestations of the disease that are likely to be the focus of test questions as these are the usual
presentation in primary eye care. However, let’s first discuss the primary infection.

Diagnostic features of primary simplex infection:
    The primary herpes simplex infection is variable in presentation, but usually presents with vesicle
      formation and sores at mucocutaneous borders coupled with significant lymphadenopathy. This
      occurs most often in children.
    Ocular formation is rare in the primary form.
    Later, secondary attacks can occur at any age and can have ocular manifestations.

Treatment of primary attacks of simplex:
ACYCLOVIR 400mg po x 7-14 days (has little effects on the number or severity of secondary attacks).

Treatment of simplex-related vesicular blepharitis without corneal involvement:
1. Cold packs and astringents (alcohol wipes, Calamine, zinc sulfate).
2. ACYCLOVIR (Zythromax) 1-5% cream tid on lids.
3. Watch carefully for ocular surface involvement.
4. Follow-up: every few days to monitor cornea

HERPES SIMPLEX KERATITIS
It would not be appropriate to treat a case of herpes simplex corneal epithelial disease with which of the following
medications:
a. prednisolone acetate*
b. trifluridine
c. bacitracin
d. vidarabine
e. acyclovir

Hint: For primary eye care, the secondary manifestation of this disease, in particular the corneal ulceration, are
of the most importance. The description of the corneal lesions in epithelial disease is usually very similar from
                                                                                                                16


question to question. In simplex corneal stromal disease, the description can be more confusing, but in both
cases, remember there is no other disease with similar findings that causes corneal desensitivity.

Diagnostic Features:
    Variable pain, variable redness, and variable vision impairment.
    Follicular conjunctivitis with enlarged preauricular nodes.
    Corneal hyposthesia (decreased sensitivity to the cornea to touch) is common, especially in recurrent
      attacks.
    Keratitis is classically an epithelial dendrite (branching, arborizing with end-bulbs) best observed
      with ROSE BENGAL stain. The newer diagnostic agent, LISSAMINE GREEN, has been discussed in
      a number of optometric publications recently and is used in the same way as ROSE BENGAL.

Treatment:
1. Corneal debridement (scraping) of loose epithelium – no proven effectiveness but advocated by some.
2. Cycloplegia if secondary iritis.
3. TRIFLURIDINE 1% (Vira-A) 1 gtt q2h until re-epithelialization, qid for 1 week thereafter.
4. VIDARABINE 1% (Vira-A) ung qhs until corneal re-epithelialized (no more staining). Often, both
    TRIFLURIDINE gtts during the day and VIDARABINE qhs are used.
5. Topical antibiotic gtts (BACITRACIN for example). This reduces “viral spread” according to some.
6. Never use steroids on epithelial disease unless there is recurrent corneal involvement.
7. Follow-up: daily
Note: For stromal or disciform forms of herpes simplex viral keratitis, topical steroids are introduced. Other
treatment options include corneal debridement (scraping), fortified antiviral and perhaps even surgery. However,
never select steroids as a treatment in epithelial herpes simplex infection. Steroids can be introduced in
stromal presentations in order to prevent damage from inflammation.


TOPICAL ANTIVIRAL PHARMACOLOGY
Adverse effects of topical antiviral
Antiviral toxicity (follicles, chemosis, superficial punctate keratitis, and retarded corneal epithelial growth) is
common with all antiviral after 1 week of use. The only real treatment for this is discontinuing antiviral
medication.

Available antiviral
1. TRIFLURIDINE 1% gtts (Viroptic) is the drug of choice for herpes simplex epithelial disease.
2. VIDARABINE 3% ung (Vira-A). Remember that this is an ointment only.
3. IDOXURIDINE 0.1% solution and 0.5% ointment (Herplex, Staxil) has been shown to be less effective and
   demonstrates more pronounced antiviral toxicities than either TRIFLURIDINE or VIDARABINE. Therefore,
   this drug is no longer considered the drug of choice.
4. ACYCLOVIR 3% ung (Zovirax) has shown some effectiveness in decreasing dendritic ulcers, but is not
   considered a primary drug of choice.

Future antiviral:
5. CIDOFOVIR is a topical antiviral that looks promising in treating a range of ocular viral disease.          Not
   approved yet, but likely to be an important drug.


HERPES ZOSTER OPHTHALMICUS
A 78 yo patient presents to the office complaining of pain on the left side of his head, a red left eye and light
sensitivity. You notice skin blister on the left side of his forehead and nose. The right side of his head appears
normal. On examination you note a few cells and flare in the anterior chamber as well as an unusual appearing
corneal ulcer of the left cornea. Appropriate treatment of this condition is:
a. acyclovir po 800mg 5x/day*
b. prednisolone acetate gtts
c. tobramycin gtts

Hints: Zoster respects the midline of the body, with the definitive treatment being ACYCLOVIR systemically
(oral pills). PREDNISOLONE or any other steroid drop is a poor choice because of the presence of corneal
                                                                                                            17


epithelial break in this case. TOBRAMYCIN is an inappropriate treatment. The most important treatment in
zoster is systemic antiviral.

Diagnostic Features:
    Older patients or history of cancer or immunosuppression.
    In a young person, think AIDS.
    Flu-like symptoms in early stage.
    Severe pain with vesicular lesions respecting midline of the head.
    Hutchingson’s sign (vesicle at the tip of the nose) often indicates ocular involvement..
    “Dendriform” keratitis with tapered ends rather than the terminal end buds seen in simplex keratitis
      ulcers.
    Stromal involvement is common.
    Iritis and inflammatory glaucoma are common, while posterior uveitis (retinal necrosis) is less common.

Treatment:
1. Internal medicine, dermatology consults indicated.
2. ACYCLOVIR (Zovirax) loading dose of 800mg 5x/day for 5-10 days (helps reduce post-herpetic neuralgia,
   especially in initial attacks and before skin lesions appear). Maintenance dosage 200mg 5x/day.
   FAMCICLOVIR 500mg tid is a newer oral ACYCLOVIR substitute.
3. Alcohol wipes, Calamide, ZINC SULFATE or other astringents to skin lesions for comfort.
4. NSAIDS (i.e. IBUPROFEN 200 – 800ms qid) for pain.
5. Topical gram+ antibiotic (e.g. BACITRACIN) qid to reduce viral spread.
6. Ocular lubricating ointments.
7. CIMETIDINE (Tagamet) po may help to reduce skin pain by unknown mechanism. CAPSAICIN 0.025%
   cream (Zostrix). This is an OTC cream used on the skin to reduce the pain associated with Zoster.
8. PREDNISOLONE ACETATE 1% (Pred Forte) q2h to qid for corneal inflammatory signs or if anterior uveitis
   is present. Use caution if corneal break is present.
9. Follow-up: if ocular involvement, follow-up in 1-7 days. If no ocular involvement, follow-up in 1-2 weeks.

Advance care:
Advanced care for herpes zoster ophthalmicus may include (depending on severity and presentation)
1. PREDNISOLONE orally 30-60mg qd for posterior uveitis or acute retinal necrosis.
2. Cycloplegics prn for iritis.
3. Aqueous suppressants for inflammatory glaucoma (beta-blockers, for example)
4. Corneal transplant if severe corneal scarring occurs.
5. Don’t forget to dilate and look at the optic nerve and retina for signs of inflammation.
6. Serotonin reuptake inhibitors (SRI’s) such as Prozac, Paxil, or Zoloft are used as adjunct therapy for post-
   herpetic neuralgia.



SYSTEMIC ANTIVIRAL PHARMACOLOGY

1. ACYCLOVIR (Zovirax) 200, 400, and 800mg tablets. Indications have been discussed above. Adverse
   effects are negligible. Has been approved for use in kids. Very safe and effective medicine. Usual dose is 5
   tablets a day.
2. FAMICYCLOVIR (Famvir) approved for treatment of zoster tid dose compared to the 5x/day dose of
   ACYCLOVIR.
3. VALACYCLOVIR (Valtrex) a prodrug of ACYCLOVIR.
4. GANCICLOVIR (Cytovene) IV 10-15mg/kg/day indicated during acute phase of CMV (cytomegalovirus)
   retinitis found in AIDS. 200md qweek maintenance. Adverse effects: bone marrow depression
   (contraindicated in patients who are also taking AZT therapy for HIV). Very toxic medicine with significant
   serious side effects.
5. FOSCARNET (Foscavir) IV 60mg/kg q8h for 3 weeks. 90mg/kg/day maintenance. Unlike GANCICLOVIR,
   FOSCARNET can be co-administered with ZIDOVUDINE (AZT). Adverse effects: renal impairment
   universal. Very toxic medicine.


ANTISEPTIC PHARMACOLOGY
                                                                                                                18



1. SILVER NITRATE 0.5% TO 1.0% is occasionally used prophylaxis of ophthalmia neonatorum and
   chemical cautery treatment of SLK.           Minimal germicidal value, caustic to mucous membrane.
   Incompatible with topical sulfonamide treatment as a precipitate is formed when the two are used together.
   Fatal if swallowed.
2. MERCURIC OXIDE 1.0% ointment. Used as a treatment for minor lid irritations and infestations such as
   pediculosis and demedecidosis. There is the risk of mercury poisoning with this compound.
3. ZINC SULFATE 0.217% sol. Astringent for minor irritation. Used by some for treating Moraxella angular
   blepharitis/conjunctivitis.
4. BORIC ACID 5% and 10% ung. Treatment of mildly inflamed and irritated eyes.

Comments: with the exceptions of the specific indicated uses, these preparations should rarely be prescribed.


SUPERIOR LIMBIC KERATOCONJUNCTIVITIS (SLK)

A 54yo woman presents to the office complaining of a red eye. She has hypothyroidism controlled with
Synthroid. She reports bilateral irritation and redness. You note on slit-lamp examination that the redness is
confined to the superior limbal quadrant of the cornea and that there is a papillary conjunctivitis. The cornea
shows superior infiltrates. Appropriate treatment might include:
a. painting the affected conjunctiva with silver nitrate 1%*
b. cromolyn sodium 4% gtts
c. a bandage contact lens

Hints: Along with ophthalmia neonaorum, SLK is the only condition in which SILVER NITRATE is a possible
treatment (although it is almost never used because of the potential for severe corneal damage). Thus,
appropriate treatment for SLK usually consists of either steroid treatment or simply lubricating eye drops. Few
other conditions present with only sector redness.

Diagnostic Features:
    Middle aged women, often with positive history of thyroid dysfunction or a history of soft contact lens
      wear (thought to be a thimerosal reaction).
    Bilateral irritation with superior corridor bulbar conjunctivitis and superior palpebral papillae.
    Limbal infiltrates in the corneal or pseudo dendrites (looks like a herpes dendrite)

Treatment:
1. Self-limiting in 10 to 15 years without treatment, thus treat according to symptoms.
2. Discontinue contact lenses/thimerosal and manage conservatively with lubricants first.
3. Pred Forte or Decadron qid for 2 weeks. This is of dubious value.
4. SILVER NITRATE 0.5% - 1.0% painted on superior bulbar and palpebral conjunctiva followed              by
lavage. Repeat weekly, usually for 2 weeks. This is also of dubious value and has the potential for serious
corneal damage. Nonetheless, this be the treatment of choice for the exam.
5. Follow-up: 1 week

MARGINAL KERATITIS (STAPH MARGINAL INFILTRATES/ULCERS)
A 64 yo man presents to the office complaining that his eyes have gotten red lately, producing some eye
discharge. You note bilateral conjunctiva redness, as well as significant blepharitis. Corneal examination shows
two 1.5mm in diameter whitish infiltrates in the right cornea, inferiorly at the 6:00 position near the limbus. The
infiltrates do not stain with flourescein. Appropriate treatment would be:
a. hot compresses with lid scrubs combined with Pred-G gtts qid*
b. erythromycin ung qhs to lids
c. prednisolone acetate gtts qid

Hints: Staph marginal keratitis generally indicates an underlying staphalococcal blepharitis. It is important to
treat the blepharitis as well as the corneal complications resulting from it. Thus, it is common to use a combo
antibiotic/steroid medication that covers staph. For the TMOD, it is important to know a lot about Staph, as this
bacterium is the cause of many different eye diseases. If you learn the process of staph and Pseudomonas
infections, you have gone a long way toward understanding ocular infectious organisms.
                                                                                                                   19


Diagnostic Features:
    Symptoms range from mild foreign body sensation to severe irritation and light sensitivity.
    Signs of infectious blepharitis, papillary conjunctivitis.
    Marginal intraepithelial infiltrates (whitish at edge of cornea) at the 8 & 4 o’clock position on the cornea
      with or without overlying epithelial defects.
    Overlying epithelial defects (staining) means you must assume that it is no longer just an infiltrate, but an
      infectious ulcer.

Treatment:
1. Hot packs qid 7-10 days
2. GENTAMYCIN / TOBRAMYCIN gtts qid, ung hs
3. Add a steroid such as PREDNISOLONE ACETATE (Pred Forte) or DEXAMETHASONE PHOSPHATE
   (Decadron) qid (or an antibiotic/steroid combo) after 24 – 48 hrs if no epithelial defect on top of the infiltrate.
   If epithelial defect is described (Flourescein staining), the select an antibiotic alone.
4. Follow-up: daily

ANTIBIOTIC – STEROID COMBINATION PHARMACOLOGY
General notes:
Many different combinations of antibiotics and steroids are currently available. Those products that contain
HYDROCORTISONE are rarely rx’ed anymore by eye doctors, but are frequently used by general medical
practitioners. Remember that Corticosporin Ophthcort both contain CHLORAMPHENICOL and thus, have its
potential serious side effects.

Most useful combinations:
1. Pred-G suspensions – PREDNISOLONE ACETATE and GENTAMYCIN
2. Tobradex solution – DEXAMETHASONE SULFATE and TOBRAMYCIN

Comment: These combo are probably the most useful combo drugs for marginal infiltrates and are also used in
routine cataract post-surgical management.

Other combinations:
1.   DEXAMETHSONE, NEOMYCIN, and POLYMYXIN B combo: Maxitrol, Dexacain, Dexasporin, Ak-trol
     suspension or ointment.
2.   DEXAMETHSONE and NEOMYCIN combo: Neodecadron ung and soln
3.   SULFACETAMIDE, PREDNISOLONE combos: Blephamide, Cetaprad, Metamyd, Vasocidin suspension
     or ung.

**These have the chance for neomycin or sulfa allergy.

Comment: The sulfa-prednisolone combos are probably antibiotically inadequate for any condition in which the
possibility of a corneal ulcer exists. They have been used in other anterior segment infections/inflammations
such as blepharitis or conjunctivitis.


BACTERIAL CORNEAL ULCER
A 16 yo girl presents to the office stating that she has a red left eye. She is a contact lens wearer and sleeps in
her daily wear lenses. She uses only saline for storage without cleaner or disinfecting solution. You see a
depressed whitish area at the 4 o’clock position on the cornea near the limbus of the left eye that stains brightly
with flourescein. Appropriate initial first treatment would be:
a. ciproflaxacin gtts q15min*
b. ciproflaxacin gtts qid
c. ofloxacin gtts qid
d. sulfacetamide gtts qid
e. prednisolone acetate gtts qid

Hints: Bacterial corneal ulcer is one of the more important conditions of the anterior segment. Be sure to know
corneal infection well.    Its probably necessary to memorize the corneal ulcer treatment protocol for
CIPROFLOXACIN (Ciloxan) and OFLOXACIN (Ocuflox) as this is likely to be the treatment of choice for a
                                                                                                                20


corneal ulcer. In any contact lens wearer, you probably need to assume it’s a Pseudomonas ulcer. You should
culture this type of lesion.

Diagnostic Features:
    Severe light sensitivity and pain.
    Extended wear SCL.
    Reduced vision.
    Clinical signs range from a small paracentral ulcer with minimal infiltrate (probably staph) to large dense
      central ulcer with blue-green discharge (Pseudomonas).
    Anterior chamber cells and flare common, often with a hypopyon (pus that forms a whitish layer in the
      bottom of the anterior chamber). Although an anterior chamber reaction is a common secondary
      response, don’t get fooled into selecting a steroid.

Treatment:
1. Lid, conjunctival, and cornea scraping for microscopic slides (Gram/Giemsa stains) and culture on blood
   agar, chocolate agar (preferential growth medium for Neisseria, Hemophilus) and Saboraud’s solution
   (growth medium for fungi) mandatory in a central ulcers. Culturing is particularly necessary if the ulcer is
   large, or it is centrally located.
2. Schematic drawing or photo documentation
3. Consider hospital admission if very severe or patient non-compliant with treatment regimen.
4. Initiate one of the following topical treatment:
   a. Fortified antibiotic to cover gram+ bacteria:
         CEFAZOLIN (Ancet) 50mg/ml or BACITRACIN 5000ug/ml
             Fortified Gram-/Broad spectrum antibiotic
         GENTAMYCIN 15mg/ml or TOBRAMYCIN 11mg/ml
             Alternating q15min until resolving, reducing to q2h until re-epithelized.
   b. CIPROFLOXACIN (Ciloxan) and OFLOXACIN (Ocuflox) are broad spectrum bactericidal
        Fluroquinolones that have been approved to treat central corneal ulcers. These are commercially
        prepared products that require no fortification. No significant adverse effects have been reported at this
        point.
        Corneal ulcer dosage: 2 gtts q15min for 6hrs,
                                   2gtts q30min for 1day,
                                   2 gtts q4h until resolved
        (sorry, you probably should memorize this and yes, that is around the clock).
5. Follow-up: 1 day

Comment: For the fortified antibiotics above, it is not likely that you need to know the dosages. In addition, with
the introduction of Ciloxan and Ocuflox, the use of fortified antibiotics for corneal ulcer treatment is becoming
less common.
         Recently, there has been much talk in the optometric literature about the differences between Ciloxan
and Ocuflox. While it is unclear whether or not the differences between the two drugs are clinically significant.
There is the suggestion that Ciloxan has a broader spectrum, is more effective against pseudomonas, is less
toxic to the cornea, and is better tolerated. In addition, some say that Ocuflox penetrates intact corneal
epithelium better, while Ciloxan penetrates non-intact epithelium better. What does this mean for the exam?
Probably that if you have to choose between Ciloxan and Ocuflox ( and this is not likely to come up) lean toward
Ciloxan.


ACANTHAMOEBA KERATITIS
A patient presents complaining of severe eye pain. He states that he is an extended-wear soft CL patient, with
his current lenses being only 6 months old. He uses a single-step chemical disinfection system. Upon further
questioning, you discover that he is an avid open-water swimmer, swimming in lakes in the area every day while
wearing his CL. Your examination shows a small corneal ulcer that is in a ring shape (worse toward the edges of
the lesion). You should suspect an infection from which of the following organisms:
a. fungi
b. acanthamoeba*
c. hemophilus
d. gonococcus
                                                                                                               21


Hints: The key to acamthamoeba are exposure to the locations where the organism lives, primarily pools, lakes
and hot tubs. These clues should suggest to you that an infection may not be just the “run of the mill” corneal
ulcer but a more serious case of corneal infection.

Diagnostic Features:
    Home-prepared saline use with soft CL.
    History of hot tub use, swimming pools or ponds as a source of infections.
    Symptoms (pain) seem to exceed severity of sign.
      “ring ulcer” is classic.

Treatment:
1. Often, patients are admitted to the hospital for treatment
2 PROPAMADIN ISENTHIONATE (Brolene), KETOCONAZOLE, MICONAZOLE, NEOMYCIN.
3. Topical steroid, bandage contact lens
4. Cycloplegia (ie ATROPINE 1% tid)
5. Oral pain medication (ie Tyleno III)
6. Corneal graft common.

FUNGAL KERATITIS
A patient presents who reports having been hit in the eye with a branch while horseback riding. You note a
raised corneal ulcer that is dirty-gray and a mild anterior chamber reaction. You should suspect that this corneal
ulcer is due to:
a. fungi*
b. pseudomonas
c. gram+ cocci
d. gram- rod-shaped bacteria
e. a herpes virus

Hints: Fungal keratitis is usually described as a corneal ulcer that results after corneal trauma from vegetation
(like this tree branch). Treatment involves using anti-fungal medications. It is uncommon for patients who do not
have AIDS, or other immune disorder, to get this type of infection.

Diagnostic Features:
    Typically found in immunocompromised (AIDS, cancer patients, diabetics), or those with a history of
      corneal injury, especially vegetative.
    Raised, dirty-gray, serpiginous (S-shaped) ulcer with ragged leading edge.
    Posterior corneal infiltrates and anterior chamber reaction (iritis) are common.

Treatment:
1. Corneal smear on a microscope slide to show the organism and agar petri dish, plating as described in the
    section on bacterial corneal ulcers (fungi can take up to a week to identify).
2. NATAMYCIN (Natacyn) 5% suspension q1h – q2h for 3-4 days then qid for 2-3 weeks. Adverse effects are
    relatively minimal. This is the only commercially prepared topical ophthalmic anti-fungal.
3. NYSTATIN (Mycostatin) 1 million units qd is used often for the systemic candidiasis seen in AIDS.
4. AMPHOTERICIN B (Fungizone) topically is used to treat endophthalmitis secondary to Candidiasis In IV
    preparation it is very toxic (nausea, vomiting and diarrhea; hematological toxicity).
5. MICONAZOLE and KETOCONAZOLE (Nizoral) are other IV and ORAL antifungals that are used in
    Candidiasis and other fungal ocular and systemic infections.
6. Cycloplegia (ie SCOPOLAMINE 0.25% tid)
7. No topical steroids and no patching
8. Follow-up: 1 day
Note: as you can see, there are several important but relatively rare types of corneal infiltration/ulceration.
Fortunately, standard practice is to treat a corneal infiltrate/ulcer as a bacterial ulcer until proven otherwise.


ALLERGIC CONJUNCTIVITIS AND KERATITIS
A patient presents to the office complaining of severe itching since the start of spring. You notice mucous ocular
discharge and swollen bulbar conjunctiva of each eye with a papillary response in the palpebral conjunctiva.
Appropriate treatment would be:
                                                                                                                     22


a.   predinisolone acetate gtts qid*
b.   TobraDex gtts qid
c.   Artificial tears qid
d.   Warm compresses and lid scrubs

Hints: Allergic conjunctivitis or allergic keratitis questions generally describe itching and a mucous stringy
discharge. Definitive treatment for allergies of all types is removal of the sensitizing agent. If that is not possible,
steroids are often used. The antibiotic in TobraDex is not appropriate in this condition. Warm compresses do
not help allergy (cool is better). While artificial tears are often used for flushing out allergens, and are often an
adjunct to allergy treatment, they are generally insufficient treatment alone.

Diagnostic Features:
 Symptoms similar to allergic dermatitis.
 Itchiness, conjunctival chemosis (swelling) with stringy mucous discharge are typical.
 Presence of papillary hypertrophy that can be dramatic (such as that seen in vernal and giant papillary
   conjunctivas).
 Superior corneal inflammation in some cases (vernal, atopic) including limbal infiltrates.

Treatment:
1. Remove antigen, if possible; Cold packs as often as possible.
2. Topical antihistamines, decongestants, or decongestant antihistamine combination drops qid.
3. Topical steroid qid for 5-7 days; (almost always necessary in delayed hypersensitivity and in cases with
   corneal signs)
4. Mast-cell stabilizers qid for 1 month or more (takes a few weeks before effect noted)
         CROMOLYN SODIUM 4% (Crolom)
         LODOXOMIDE 0.1% (Alomide) tid – qid
         OLOPATADINE 0.1% (Patanol) bid. New mast cell stabilizer with antihistamine properties as well.
            Has the advantage of twice a day dosage.
         NEDOCROMIL (Tilade) Mast cell stabilizer, not on the market yet.
5. Oral over-the-counter anti-histamines have little effect on ocular symptoms. However, they are often used
   to treat systemic symptoms such as rhinitis.
6. Follow-up: few weeks
TOPICAL ANTIHISTAMINE AND DECONGESTANT PHARMACOLOGY

ANTIHISTAMINE:

LIVOCABASTINE 0.05% qid (Livostin) is the only pure topical ophthalmic antihistamine. Reports indicate it has
far more efficacy than previous decongestant-antihistamine products in the treatment of allergic conjunctivitis.

DECONGESTANTS:

NAPHAZOLINE 0.1% (Naphcon, Vasocon)
TETRAHYDROZOLINE, OXYMETAZOLINE, and PHENYLEPHRINE (Clear Eyes, Allerest, Viseine, Murine).

Adverse effects: rebound hyperemia, mydryasis (use caution in patient with narrow angles).

Certain over-the-counter decongestants have been combined with various other products that generally reduce
discomfort, such as ANTIPYRINE (an anesthetic) or ZINC SULFATE: Sincfrin, Prefrin, Vasoclear A, and Visine
AC

DECONGESTANTS AND ANTIHISTAMINE COMBINATIONS:

ANAZOLINE 0.5% and NAPHAZOLINE 0.05% (Vasocon-A, Albalon-A)
PHENIRAMINE 0.3% and NAPHAZOLINE 0.025% (Naphcon-A)
These are now non-prescription products that combine a decongestant with an antihistamine, either
ANTAZOLINE or PHENIRAMINE and are probably more useful than those medicines that have only
decongestants.
Adverse effects: Same as in decongestants with a slightly increased pupil dilation risk and increased
hypersensitivity possibility.
                                                                                                              23



ROSACEA (ACNE ROSACEA)
A 55 yo woman presents to the office complaining of ocular irritation. She states that her eyes just “don’t feel
right.” You notice redness of the eyelid margins of each eye as well as a red, swollen nose and a mild bulbar
conj hyperemia. Appropriate treatment would not include:
a. prednisolone acetate 1% gtts*
b. tetracycline 250mg qid po
c. artificial tears as needed
d. erythromycin ung

Hints: Rosacea treatment involves treating either the skin by using METRONIDAZOLE or by treating
systemically with TETRACYCLINE, even though the disease is not caused by any infectious organism.
Remember the characteristic skin appearance in rosacea and remember that standard blepharitis treatments are
not effective.

Diagnostic Features:
    Pts are middle-aged and primarily of Northern European descent.
    Rhynophyma (enlarged nose), telangiectasis of nose (small superficial blood vessels), cheeks,
      forehead, and neck
    Possibly accompanied by blepharitis, conjunctivitis, peripheral corneal inflammation and uveitis.

Treatment:
1. TETRACYCLINE 250mg qid po (ERYTHROMYCIN if tetracycline contraindicated) for 4-6 weeks.
2. Pred Forte (PREDNISOLONE ACETATE) qid for any corneal inflammatory sign.
3. METRONIDAZOLE 0.75% gel (MetroGel) bid topically to affected skin areas for 3-9 wks (this is an anti-
    protazoal medication with an unknown mechanism of action in rosacea). Recent comments describe use of
    this medication on eyelids as well.
4. Reactivations common so retreat accordingly.
5. Follow-up: weeks

UVEITIS
A patient presents complaining of an aching, red right eye that has occurred over the past few days. This patient
is a 23 yo man, who states that he has never had anything like this occur before. Your exam reveals the
appearance of grade 1 cells and flare in the anterior chamber of the affected eye, and small deposits on the
corneal endothelium of that eye. Appropriate treatment of this patient would be:
a. homatropine gtts and prednisolone acetate gtts*
b. cyclopentolate gtts and medrysone gtts
c. tropicamide 1% gtts and prednisolone acetate gtts
d. homatropine gtts and medrysone gtts

Hints: Uveitis is one of those conditions in which there is a vast array of possible causes. However, treatment
is reasonably straightforward, with the mainstay of ocular treatment being topical corticosteroids (usually
PREDNISOLONE ACETATE 1%) combined with cycloplegia. TROPICAMIDE is too weak a cycloplegia and
CYCLOPENTOLATE is only effective for very mild uveitis cases. The cyclopegia generally consists of
HOMATROPINE or ATROPINE. Remember the steroid side effects!

Diagnostic Features:
    Deep ache that worsen with illumination
    Perilimbal injection
    Miosis
    Reduced IOP, anterior chamber cells and flare
    Keratic precipitates (cells) on endothelium of cornea

Treatment:
1. If inflammatory cells limited to anterior chamber and anterior vitreous:
    Topical steroid: PREDNISOLONE ACETATE 1% q1h (severe) to qid (very mild).
    Systemic steroids are sometimes used for very severe anterior uveitis that is non-responsive to topical
    treatment.
                                                                                                                  24


     Cycloplegia: HOMATROPINE 5% bid to ATROPINE 1% tid depending on severity of anterior chamber
     reaction.
2.   Posterior vitreous cells imply the need for systemic treatment that depends upon the etiology of the
     inflammation (infection vs. inflammation vs. neoplasia).
3.   Follow-up: depends on severity, (1-7 days)


Diagnostic features of posterior uveitis:
    Distorted vision
    Macular edema,
    Disc edema
    Posterior vitreous cells (behind iris in vitreous cavity)
    Retinal exudates
    Vascular sheathing
    Minimal or no discomfort

Treatment of posterior uveitis:
Usually involves systemic steroids.

STEROID PHARMACOLOGY

I.      TOPICAL STEROIDS:
        Notes: Acetates are suspensions and must be shaken; phosphates and alcohols are solutions and
        do not need to be shaken.

        PREDNISOLONE ACETATE 1% (Pred Forte, Econopred Plus, A-K Tate)
        PREDNISOLONE ACETATE 0.125% (Pred Mild, Econopred)
            Pre Forte is the drug of choice for anterior uveitis; it’s the most potent topical steroid and has
             good corneal penetration.
            If in doubt which steroid to select as a treatment, Pred Forte is a good guess.
            Of all the topical steroids, Pred Forte has the highest incidence of:
             1. Intraocular pressure increase or glaucoma (steroid response)
             2. Posterior subcapsular cataract

        PRENISOLONE SODIUM PHOSPHATE 1% (Inflamase Forte), 0.12% (Inflamase).
            Less corneal penetration than PREDNISOLONE ACETATE.
            Not considered as effective in anterior uveitis treatment by some authorities.

        DEXAMETHASONE PHOSPHATE 1% solution (Decadron, AK-Dex)
        DEXAMETHASONE PHOSPHATE 0.05% ung (Decadron, AK-Dex)
        DEXAMETHASONE SUSPENSION 0.1% susp (Maxidex)
            Powerful steroid that has less corneal penetration than PREDNISOLONE.
            Ointment form useful for nighttime treatment or in poorly compliant patients.
            Appropriate alternative to PREDNISOLONE in anterior uveitis.

        FLUOROMETHALONE SUSPENSION AND OINTMENT 0.1% (FML)
        FLUORMETHALONE SUSPENSION 0.25% (FML forte)
        FLUOROMETHALONE ACETATE 0.1% (Flarex, Eflone)
            Powerful steroid with minimal penetration in suspension form.
            Less IOP response and less cataract formation but considered less effective.
            Flarex supposedly comparable to Pred Forte in anterior uveitis treatment with less chance to
             increased intraocular pressure. Flarex is still being evaluated by practitioners.


        RIMEXOLONE 1% (Vexol)
            Indicated for treatment of post-operative inflammation and anterior uveitis.
            Early claims are that its efficacy is comparable to Pred Forte, but like Flarex, it is a new drug.
                                                                                                                    25


      MEDRYSONE 1.0% (HMS)
         Minimal corneal penetration and questionable practical efficacy makes HMS a dubious choice
           except in minimal, superficial anterior segment inflammation.
         Least side effects, but also least effective in treating anterior uveitis.

      LOTEPREDNOL 0.5% (Lotemax) 0.2% (Alrex) approved in US in 1998.
          Not as effective as Pred Forte but reduced risk of IOP increases compared to Pred Forte.
          The O.2% is marketed as a treatment for allergic conjunctivitis treatment while the o.5% is being
           compared to PREDNISOLONE ACETATE.

      Adverse effects and contraindication in topical steroid use
      Relative contraindications:
       Diabetic, immunocompromised patients: steroids reduce healing
       Nonspecific corneal defects: steroids hinders re-epithelialization
       Topical steroids can induce herpes simplex and herpes zoster attacks

      Absolute contraindications:
       Herpes simplex dendritic keratitis
       Bacterial corneal ulcers

      Treatment of complications of anterior uveitis and steroid treatment:
      1. Increased IOP secondary to either steroid use or inflammation: treat with aqueous suppressants
         (topical Beta-blocker), NOT miotics (PILOCARPINE).
      2. Steroid cataract: treatment by limiting the length of treatment; cataract surgery prn.
      3. Posterior synechiae (adhesion between iris and lens): PHENYLEPHRINE 10% and ATROPINE
         q15min x 1-2 hrs to break. Watch for systemic effects at this high dosage from both these
         medications.
      4. Peripheral anterior synechiae: compression gonioscopy to break; aggressively treatment with
         steroids.
      5. Topical steroids must be tapered to avoid rebound inflammation. Length of tapering should
         correlate with duration of treatment and type of inflammation.
         Example: anterior uveitis requires much slower tapering (days to weeks) of the steroid than does
         post-operative inflammation.


II.   SYSTEMIC STEROIDS

      Indications:
      1.    Ocular diseases secondary to systemic inflammatory disease (Type IV hypersensitivity reactions,
            giant cell arteritis)
      2.    Posterior segment inflammation
      3.    Severe anterior uveitis not responsive to topical therapy

      PREDNISONE (oral)
      5mg is the minimal anti-inflammatory dose. 100mg qd – 120mg qd is often prescribed for some
      life/vision threatening acute inflammatory diseases (i.e., giant cell arteritis, also called temporal arteritis).

      METHYPREDNISOLONE (oral, injectable, topical) 80mg (Depomedrol) and
      TRIAMCINOLONE (Kenalog) 40mg
      Commonly used in injection for subtenon treatment of retinal, posterior uveal and scleral inflammation
      (cystoid macular edema or CME), also used in injection to treatment chalazia.

      HYDROCORTISONE (oral, injectable, and topical)
      Most commonly used in eye care as a topical cream for treatment of dermatitis in a 0.5% or 1.0%
      formulation. Used caution with 1% in patient with darkly pigmented skin as it may depigment skin.

      Adversed effects of not with systemic steroid use:
      1. Increased blood glucose level (use caution in diabetics)
      2. Redistribute body fat (spider body, moon face, buffalo hump)
                                                                                                               26


        3. Suppresses immune response and delays healing (diabetics, again)
        4. Ocular side effects can occur with systemic use (usually after long-term systemic treatment)

LABORATORY TESTING IN UVEITIS
You elect to order laboratory testing for the patient in the previous question to further delineate the condition.
The most appropriate test to order would be:
a)     FTA-ABS*
b)     Gallium scan
c)     Cultures and sensitivities

Hints: Uveitis laboratory testing can be confusing. We’ve broken it down below to give you a framework for
thinking and remembering this area.

When to consider systemic testing:
1. Multiple episodes
2. Bilateral cases
3. “Granulomatous” cases (implies chronicity; defined by the presence of iris nodules and large, so-called
   “mutton-fat” keratic precipitates)
4. Children

Tests commonly a part of all lab uveitic work-ups include:
1. Complete blood count (the CBC is an indicator of general health)
2. Erythrocyte sedimentation rate (the ESR is an indicatory of systemic inflammation)
3. Chest x-ray (used to check for sarcoid and tuberculosis)
4. A test for syphyllis (FTA-ABS; MHA-TP, VDRL)

Additional tests:
These should be selected based upon the specific history and presentation:
1. Young adult males with recurrent, chronic, or bilateral uveitis often have one of 3 common systemic
   syndromes that test positive for the “major histocompatability complex” B-27, (HLA-B27). So a patient
   testing positive for HLA-B27 and having:
   a. burning with urination and/or pain in the legs  REITER’S DISEASE (urinalysis and rheumatoid
        factor are both negative)
   b. a stiff lower back  ANKYLOSING SPONDYLITIS (generative changes in the sacroilliac joint/lower
        spine x-ray)
   c. joint pain and lower gastrointestinal pain or diarrhea  CROHN’S DISEASE or ULCERATIVE
        COLITIS ( lower gastrointestinal studies are needed)
                                                                                                                 27


2. A child with mild to moderate anterior uveitis, band keratopathy, and arthritis  JUVENILE RHEUMATOID
   ARTHRITIS (JRA).
   a. Antinuclear antibody (ANA) is often in JRA, but a negative result does not rule out JRA.
   b. Pediatric consultation
   c. Serum rheumatoid factor is negative

3. Middle aged blacks with panuveitis, “mutton fat,” keratic precipitates  SARCOID. Testing to consider:
   a. Chest x-ray: hilar lymphadenopathy (lungs)
   b. Blood serum angiotensin converting enzyme (ACE): elevated
   c. Serum lysozyme: elevated
   d. Kviem test
   e. Gallium scan


4. Patient with a cough along with uveitis  TUBERCULOSIS (TB). Testing needed in suspected TB:
   a. Positive purifies protein derivative (PPD; Mantoux), the standard TB skin test
   b. Sputum culture: grows acid fast bacilli (Mycobacterium)
   c. Chest x-ray


Other uveitic syndromes of note:

1. POSNER – SCHLOSSMAN SYNDROME (aka glaucomatocyclitic crisis): episodes of unilateral high IOP
   (45 or more) and mild uveitis. Treatment is to reduce IOP with aqueous suppressants; no treatment is
   usually indicated for the anterior chamber reaction.

2. PHACOLYTIC (lens protein) GLAUCOMA: associated with hypermature cataract for which the treatment is
   lensectomy (removal of lens and capsule).

3. FUCH’S HETEROCHROMIC IRIDOCYCLITIS: heterochromia (differing iris colors between the two eyes),
   mild iritis, and variable IOP. No treatment is necessary for the uveitis, but the patient is at risk for the POAG
   and should be followed as a glaucoma suspect.


PRIMARY OPEN ANGLE GLAUCOMA
A glaucoma patient presents to the office for his routine 3 months follow-up. This patient’s IOP has been well
controlled at the 19mmHg level with timolol 0.5% q12h in each eye. Your exam today shows a pressure of
24mmHg, which you believe to be too high. An appropriate medication to add to this patient’s timolol drop would
be:
a)       Pilocarpine*
b)       Levobunolol
c)       Betaxolol
d)       Metipranolol

Hints: Primary open angle glaucoma questions fall into three categories: (1) begin treatment on a newly
diagnosed glaucoma patient, (2) modify an existing treatment, (3) and deal with medication side effects. In the
above question, you need to know two things: that all the other choices are beta-blockers, and that the
appropriate next step in therapy is to add pilocarpine to the beta-blocker therapy. Adding a beta-blocker to
another beta-blocker is not appropriate therapy.

Note on studying glaucoma:
Of all topics in primary eye care treatment, glaucoma may be the most difficult to get a handle on. There are
many medications that are used, and it seems that every reference you turn to has a slightly differing way of
treating or modifying the treatment of glaucoma patients. However, if you stick to one flowchart of treatment, you
should be fine with modifying treatment of glaucoma patients.

Diagnostic Features:
    IOP > 21
    (+) family history
                                                                                                               28


       diabetic,
       history of steroid use
       older age group
       documented loss of optic nerve tissue
       visual field loss (nasal step, paracentral scotoma, arcuate scotoma).

Treatment:
1. Set target pressure based upon untreated pressure, health of nerve, visual field. There are many rules for
   setting target pressures (i.e., 20 for early glaucoma, 16 for moderate glaucoma, and 12 for severe cases).
   Most authorities like to see IOP below 18 in anyone with demonstrated loss of nerve or else visual field loss.
   Another common “rule of thumb” for determining target pressure is to use the pre-treatment IOP in the form
   of a percentage to estimate the amount of pressure lowering needed. That is, if the pre-treatment IOP is 28,
   then you need a 28% drop in IOP, or about 8mmHg of pressure lowering (thus a target pressure of
   2ommHg).
2. Treatment in stepped-care method. Thus, follow a flowchart of treatment. (Use the one presented in one of
   your reference texts or in the manual presented with your TPA course).
3. IOP checks from every 2 to 4 months when stable. Perform a threshold visual field exam and dilated fundus
   exam annually.
4. Set lower target pressure and add to treatment if progression is determined.

STEP 1: OF THE IDEALIZED TREATMENT STEPS
1. START WITH A TOPICAL BETA-BLOCKER
   a. Non-selective topical beta-blocker drops (affects lungs as well as cardiovascular system); usual dose is
       bid.
             TIMOLOL 0.25%, 0.5% sol (Timoptic, Timoptic XE, Betimol)
             METIPRANOLOL 0.3% sol (Optipranolol)
             CARTEOLOL 0.5% sol (Ocupres)
             LEVOBUNOLOL 0.5% sol (Betagan)
       Adverse effects of beta-blocker therapy:
       Bradycardia, hypotension, bronchoconstriction, CNS (mental depression), iritis have been reported with
       metipranolol. Timoptic XE is a gel that has qd dose. DO NOT USE NON-SELECTIVE BETA-
       BLOCKERS IN PATIENTS WITH PULMONARY DISEASES AND AVOID IN PATIENTS WITH HEART
       FAILURE.

    b. Selective beta-blockers (have far less effect on lungs)
            BETAXOLOL 0.25% suspension (Betoptic-S)
            BETAXOLOL 0.5% sol (Betoptic)
       Better choice for patient with history of pulmonary disease, but is probably less effective than non-
       selective beta-blockers

STEP 2: IF PRESSURE IS STILL NOT LOW ENOUGH…
2.. ADD :
    a. SYMPATHOMIMETIC
            EPINEPRINE 0.5-2.0% (Epifrin, Glaucon) bid (1% is the most frequently rx’d)
            DIPIVEFRIN 0.1% (Propine) bid
        Comments: (1) Propine is the prodrug of epinephrine (turns into EPINEPHRINE in aqueous). (2)
        Penetrates the corneal epithelium better than EPINEPHRINE, therefore, has greater efficacy and fewer
        systemic side effects. (3) Has little IOP lowering effect combined with beta-blockers, especially the non-
        selective drugs (like TIMOLOL). Few use epinephrine anymore.
        Adverse effects of note:
        Adrenochrome deposits in cornea and conjunctiva; cystoid macular edema (macular swelling) in
        aphakes and pseudoaphakes; conjunctivitis.

   b. TOPICAL CARBONIC ANHYDRASE INHIBITOR
          DORZOLAMIDE (Trusopt) bid to tid
          BRINZOLAMIDE 1% (Asopt) bid dose (approved in US mid 1998)
      Caution in patient with sulfa allergies. Some think that these drugs have poorer efficacy in blacks. Far
      fewer side effects than systemic CAI like Diamox.
                                                                                                              29


   c. PILOCARPINE
              PILOCARPINE 0.25, 0.5, 1, 2, 3, 4, 5, 6, 8, 10% sol (Pilocar) qid. (1,2,4% are the most
                 commonly prescribed concentrations).
              PILOCARPINE 4% gel (Pilopine HS) equivalent to PILOCARPINE 1% qid, used at bedtime.
              Ocusert (P-20 equivalent to PILOCARPINE 1%, P-40 is equivalent to PILOCARPINE 2%) q1wk.
                 This is a sustained released PILOCARPINE system.
        Adverse effects to note:
        Browache, induced myopia, ciliary spasm, headache, risk of retinal detachment. As a rule, the more
        significant systemic side effects occur with beta-blockers, the more significant ocular effects with
        pilocarpine.
        Comment: Pilocarpine increased aqueous outflow, while beta-blockers and CAI reduces aqueous
        secretion.

STEP 3: IF THE PRESSURE IS STILL NOT LOW ENOUGH
3. ADD ORAL CARBONIC ANHYDRASE INHIBITOR
            METHAZOLAMIDE (Neptazane) 25 or 50 mg bid-tid po
            ACETAZOLAMIDE (Diamox) 125, 250mg qid po, 500mg sequels bid po
            DICHLORPHENAMIDE (Daranide) 25-50mg qd to tid po
       Comments: effective medicines with significant side effects. METHAZOLAMIDE has fewer, but still
       significant, side effects than others.
       Adverse effects to note:
       Caution in patients with sulfa allergies
       Diuresis
       CNS: parasthesia (tingling, metallic taste), fatigue, weakness
       Kidney stones, may be less with Neptazane
       GI upset
       Hematological, dermatological, and pulmonary adverse effects

STEP 4: LASER OR SURGICAL PROCEDURES
   1. ARGON LASER TRABECULOPLASY (ALT, LTP): most often used after topical therapy fails. . . or as
       an alternative to medical therapy, especially in non-compliant patient.
   2. FILTERING SURGERIES: TRABECULECTOMY (5-FU and MITOMYCIN C are used during surgery to
       improve surgical success)
   3. HOMIUM LASER THERMOSCLERCTOMY
   4. IMPLANT FILTRATION (MOLTENO, etc)
   5. CILIARY BODY CRYOTHERMY or DIATHERMY
       Most consider these surgical procedures after topical drug therapies fail.


SECONDARY OPEN-ANGLE GLAUCOMA:

PIGEMENTARY GLAUCOMA

Diagnostic Features:
    Young male
    Low myopia;
    Pigment dispersion syndrome with corneal endothelial pigment (Kruckenberg spindle); iris
      transillumination defects (loss of iris pigment); posteriorly bowed peripheral iris; and trabecular pigment
      seen on gonioscopy. The pigment is believed to have been rubbed off the posterior iris surface by the
      lens zonules then plugging and damaging the trabeculum to cause increased IOP.

Treatment:
1. Topical miotics if tolerated (such as low-dose PILOCARPINE)
2. Laser iridectomy
3. Aqueous suppressant (such as TIMILOL)
4. Avoids sympathomimetics (they dilate the pupils and may exacerbate the pigmentary dispersion.


PSEUDOEXFOLIATIVE GLAUCOMA
                                                                                                                30



Diagnostic Features:
    Older blacks or Northern European females
    Flaky grey-white dusting on the iris and dusting in a bulls-eye pattern on anterior lens capsule
    Angle pigment.

Treatment:
Same as primary open angle glaucoma; ALT rarely may be of benefit.




ACUTE NARROW ANGLE GLAUCOMA
A patient comes into the office without an appointment complaining that over the last hour, the vision in his right
eye has gotten much worse. He now reports feeling “sick to his stomach” as well. You note a hazy cornea with
an IOP of 56mmHg. Gonioscopy shows the presence of a closed angle in the affected eye. The best initial
therapy would be:
    a. pilocarpine gtts, acetazolamide IV, timolol gtts*
    b . pilocarpine gtts
    c. timolol gtts
    d. laser iridotomy
    e. acetazolamide po

Hints: The important issues with acute narrow angle glaucoma are the emergency management of this
condition or the possible side effects of medications used in its treatment. The side effects are pronounced
because higher doses than usual glaucoma management are used. The goal in any case is to lower the
pressure and quiet the eye enough so that a laser iridectomy or iridotomy can be performed, which is the
definitive treatment of this condition.

Diagnostic Features:
    Deep boring pain
    Nausea
    Hyperopia
    IOP elevated
    Haloes
    Mid-dilated pupil
    Steamy cornea,
    Iritis

Treatment:
(For angle closure, follow the steps in the order listed)
1. Gonioscopy confirms closed angle. Possibly cannot visualize angle because of corneal edema. Ophthalgan
    is a topical glycerin solution applied to the cornea to reduce corneal edema (painful).
2. A systemic osmotic agent:
    a. Oral “syrups” mixed with fruit juice:
              GLYCEROL 50% (Osmoglyn); contraindicated in diabetics
              ISOSORBIDE 45% (Ismotic)
    b. Or IV (oral osmotics are often poorly tolerated by nauseated patients):
               MANNITOL 1.0 – 2.0 gm/kg IV; also a sugar so contraindicated in diabetics
3. CAI:
               ACETAZOLAMIDE (Diamox) 250-500mg po or IV (two 250mg pills are considered to be more
                  rapidly absorbed than one 500mg sequel which is a sustained release formulation).
4. Topical beta-blocker q10min for 2 doses
5. APRACLONIDINE 1% q10min for 2 doses
6. Check IOP, gonioscopy every 30 min; once IOP is below 40, add PILOCARPINE 2% q15min until
    trabeculum visualized by gonioscopy.
7. Add PREDNISOLONE ACETATE 1% q2h to qid to reduce anterior uveitis and reduce chance of synechiae
    formation.
                                                                                                               31


8.   Laser iridotomy / surgical iridectomy is the definitive cure for narrow angle glaucoma.
9.   Follow-up: iridectomy treatment in 1 week

Note: for angle closure attack, remember the flow above, and the fact that you will need to do almost all of the
above steps in the above order in most cases.


PHARMACOLOGY OF OTHER IMPORTANT GLAUCOMA DRUGS

1. APRACLONIDINE 0.5% (Iopidine) bid-tid
   It’s an alpha-adrenergic drug first used in a 1% concentration to temporarily reduce IOP in pharmacologically
   non-responsive patients prior to filtration surgery or in the prevention of IOP rises due to laser procedures.
   Now approved for use in POAG as 0.5%. Works well but the effects usually doesn’t last more than a few
   weeks. There seems to be a high incidence of allergic conjunctivitis. Can increase heart rate.
   APRACLONIDINE is a possible alternative in open-angle glaucoma therapy. It is certainly useful in short-
   term secondary glaucoma and narrow-angle glaucoma treatment.

2. BRIMONIDINE (Alphagan) bid-tid
   Newer apha-adrenergic drug that seems to have fewer side effects than APRACLONIDINE in terms of both
   heart rate increasing effects and allergic effects. Has about the same IOP effects as beta-blockers but may
   be safer. Can cause dry mouth or fatigue. Appropriate for use if beta-blockers are contraindicated. Some
   are advocating this drug as a first-choice medication.

3. CARBACHOL 3% tid
   Occasionally used if PILOCARPINE therapy fails. It has little advantage over 4%      PILOCARPINE and has
   the same kinds of ocular side effects but more intense. In addition, it causes GI distress that is not usually
   seen with PILOCARPINE use.

4. PHYSOSTIGMINE 0.25% sol and ung, 0.5% sol qid (Eserine)
   Anticholinesterase drug that is usually seen in patients who have been successfully using it for years. Ocular
   side effect of not is formation of iris cysts, and anterior subcapsular cataracts, both of which can results in
   reduced VA. Used caution in patients exposed to organophosphate insecticides (such as farm workers) since
   PHYSOSTIGMINE can add to the toxic side effects of these chemicals. PHYSOSTIGMINE must be
   discontinued before anesthesia.

5.    ECHOTHIOPHATE 0.03%, 0.125% (Phospholine Iodide)
     Rarely seen and has the same problems with iris cyst formation and anterior subcapsular cataract formation
     in prolonged use that occur with PHYSOSTIGMINE. Has been used in treatment of accommodative
     esotropia.


6. ISOFLUROPHATE 0.025% ung (Floropryl) bid
   Almost never used because of very long duration (1month).

7. PILOCARPINE and EPINEPHRINE (P1E1, etc) bid – qid
   Rarely used combo

8. LATANOPROST (Xalatan) qd
   New glaucoma medication that is already an important therapy. Seems to be quite effective in lowering IOP
   and has the significant advantage of qd dose. It is a prostaglandin antagonist that lowers IOP through
   increasing uveo-scleral outflow. In addition, it has the unusual side effect of increasing iris pigmentation.
   Currently, LATANOPROST is not approved as first-line glaucoma therapy. Also of note is that it is not
   additive to PILOCARPINE as both drugs increase outflow.

9. Cosopt is a combination of DORZOLAMIDE and TIMOLOL MALEATE

10. BRINZOLAMIDE (Azopt) is a very new CAI like DORZOLAMIDE; it is said to sting less upon instillation than
    DORZOLAMIDE.
                                                                                                                 32



A note on new drugs in glaucoma:
As you can see, new drugs are introduced for glaucoma regularly. While you may hear in lectures different
schemes of glaucoma treatment than the standard we present here, we suggest that you follow our more
standard therapy. The point at which a new drug is utilized in therapy is controversial for some time after
introduction. An example would be LATANOPROST. While an excellent medication that some advocate for
early use in glaucoma therapy, this medication is still not approved as first-line therapy by our FDA. Therefore, it
is unlikely to be presented as initial therapy in a test situation.

GRAVES OPHTHALMOPATHY
A patient with thyroid problems presents to the office complaining of red eyes. You note significant
exophthalmos of each eye and slit lamb examination reveals superficial punctuate staining in each inferior
cornea. Appropriate therapy would be:
a.     artificial tears qid OU*
b.     prednisolone sodium phosphate gtts qid
c.     tobramycin gtts qid

Hints: Grave’s disease treatment generally consists of treating the exposure keratitis that is produced. This is
where lubricants such as artificial tears and ointments are prescribed.

Diagnostic Features:
    Proposes (exophthalmometry)
    Diplopia
    Lid retraction
    Lid lag (aka Von Graefe’s sign – lid lag on down gaze)
    EOM restrictions and palsies
    Tremor
    Lab tests (“thyroid panel”): TSH levels, T4 levels, and T3 Uptake are abnormal. CT and ultrasound
      demonstrate enlarged, inflamed EOM’s and in advanced cases, deep orbital congestion.

Treatment:
1. Ocular lubricants prn (artificial tears, ung at bedtime).
2. Treat orbital inflammation and congestion (lid swelling, injection, myosis, and proptosis).
   a. ACETAZOLAMIDE (Diamox) 1gm qd po to reduce fluid in orbital and periorbital spaces.
   b. PREDNISOLONE 30-50mg qd po 4-6mos.
3. Retrobulbar or subconj infection of METHYPREDNISLONE (Depomedrol) 80mg (see side effects).
4. Unresolving inflammation or else optic nerve compression often requires orbital decompression.
5. Internal medicine consult to treat thyroid gland:
   a. Medicines: METHIMAZOLE (Tapazole), PTU
   b. Surgical ablation
   c. Radiation
6. Follow-up: depends on severity and therapy. Patients with proptosis are generally seen every 3-6 months.
                                                                                                                   33


DIAGNOSTIC PUPIL TESTING
A patient comes into the office for a routine eye examination with no complaint. During pupil examination, you
find that the right pupil is large than the left and seems to have unusual movements at the margin that you note
during slit-lamp examination. Pharmacologic testing of this pupillary disorder would likely include:
a. pilocarpine 0.1%*
b. cocaine 10%
c. hydroxyamphetamine 1%
d. phenyephrine 2.5%

Hints: Pupillary disorder questions primarily relate to Adie’s pupil or Horner’s pupil as these are the two pupil
disorders that have pharmacologic diagnostic considerations. The key is to remember that if the affected pupil is
large, then you try to constrict it with mild pilocarpine (either 0.1% or 0.15%). If the abnormal pupil is small, then
you try to dilate it with either COCAINE or HYDROXYAMPHETAMINE (Paradrine).


I.      Adie’s or Tonic pupil
        Diagnostic Features:
            Mydriasis in light
            Sluggish appearance
            Young women
            Reduced joint reflexes
            Vermiform movement of the iris pupillary margin (moves like a worm), benign diagnosis.
        Diagnostic Procedure:
        1. PILOCARPINE 0.125% to affected eye
        2. If no constriction  this is a case of simple anisocoria or pharmacologic dilation
        3. If constriction  the patient has Aide’s
        Prognosis: excellent

II.     Horner’s pupil
        Diagnostic Features:
            Miosis in the dark
            Elderl
            Smokers (lung cancer)
            History of trauma in you
            Ptosis and anhydrosis (lack of sweating, which can result in increased skin temperature) on
                 side of affected pupil.
        Diagnostic Procedure:
        1. COCAINE 10% 2gtts, 5min apart to affected eye
           If no dilation  parasympathetic lesion, go to step 2
           If dilation  physiological anisocoria
           Wait 24 hours, then
        2. HYDROXYAMPHETAMINE 1% (Paradrine) 2gtts, 5 min apart to affected eye
                                               rd
           If no dilation  post-ganglionic (3 order) neuron lesion
                          Work-up: r/o orbital disease. Most likely trauma-induced.
                                          st      nd
           If dilation  pre-ganglionic (1 or 2 order) neuron lesion
                          Work-up: MRI of lung, internal medicine consult to r/o cancer

DRUGS OF NOTE:
The remainder of Chapter 3 consists of descriptions of commonly used medications that you need to know for
primary eye care that have not been covered elsewhere.


NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAID’S) PHARMACOLOGY

Introductory comments:
1. Naiad’s inhibit the synthesis of prostaglandins (chemical mediators of inflammation) and therefore reduce
    platelet aggregation (inhibit blood clotting – use caution with patients taking blood thinners such as
    WARFARIN).
                                                                                                                 34


2. NSAID’s also have other therapeutic benefits besides reduction of inflammation: analgesia (reduce pain);
   anti-pyretic (reduce fever).
3. Anti-inflammatory dose typically is larger than dose for pain or fever.

ASPIRIN (Acetysalacylic acid, ASA)
    Analgesia and fever  600mg qid; anti-inflammatory  1gm qid
    Indications: pain, fever, and inflammation relief. Lower doses are used in the prevention of myocardial
      infarction or after a retinal vein occlusion.
    Adverse effects: GI upset, Reye’s syndrome (avoid in children as this can be fatal), tinnitus (ringing in
      the ears), and renal damage with long-tern use.

IBUPROFEN (Motrin, Avil)
    Analgesia and fever  200-400mg qid; anti-inflammatory  800mg qid
    Indications: same as ASPIRIN (except IBUPROFEN has no effect on blood coagulation and thus is not
      used to prevent myocardial infarction).
    Adverse effects: less GI upset, interaction with anticoagulants uncommon; renal and GI toxicity with
      long-term use.

NAPROXEN (Naprosyn)
    Anti-inflammatory  375mg bid
    Indications and adverse effects same as IBUPROFEN except more expensive.


OTHER NSAIDS:

1. INDOMETHACIN (Indocin) is the most potent NSAID and is used only for anti-inflammatory conditions and
   not general pain or fever reduction. It is especially indicated for ankylosing spondyitis and gout. Topical
   Indocin 1% qid has been used to treatment cystoid macular edema (but must be specially compounded
   for this application).
2. PHENYLBUTAZONE is a highly toxic NSAID that is used in the short-term treatment of severe acute, painful
   inflammatory conditions like scleritis.
3. PIROXICAM (Felden) has a qd dosage.
4. ACETAMINOPHEN (Tylenol) 325 – 500mg qid is useful for pain and fever control, but has no anti-
   inflammatory properties.

TOPICAL NSAIDS:

Introductory Comments:
These drugs are used primarily for pain control from corneal abrasions or post-PRK surgery.
1.   KETOROLAC 0.5% qid (Acular): indicated for ocular itching secondary to allergic conjunctivitis.
2.   FLURBIPROFEN 0.03% (Ocufen): control intraoperative miosis in eye surgery, but has been used to
     control pain and inflammation in some anterior segment conditions like trauma.
3.   DICLOFENAC 1.0% (Voltaren): indicated to reduce post-operative inflammation from cataract surgery and
     reduce post-PRK pain.

Important Note on Topical NSAID Drugs:
Toward the end of 1999, Alcon removed DICLOFENAC from the market due to concerns about reports of
serious corneal problems such as reduced healing, erosions, and keratitis perhaps associated with the drug’s
use before, during and after cataract surgery. It is unclear how these reported complications will affect the use of
these drugs in the future. For the exam, knowing the information above is probably the best course, while
keeping in mind that there are reported complications.


RHEUMATOID ARTHRITIS TREATMENT DRUGS
 GOLD
 HYDROXYCHLOROQUINE (Plaquenil) can create macular changes
 METHOTREXATE (Rheumatrex)
PHARMACOLOGY OF NARCOTICS
                                                                                                            35


Introductory comments:
Narcotics are indicated for the reduction of severe pain as the result of trauma, surgery, and painful diseases
such as bacterial corneal ulcers or Herpes Zoster ophthalmicus.

Adverse effects are proportional to the potency of the narcotics and can be severe:
      1. CNS: analgesia, inhibited respiration, vomiting, antitussive, euphoria
      2. Hyperglycemia (use caution in diabetics)
      3. Constipation
      4. Red, itchy skin (due to antihistamine release)
      5. Tolerancy and dependence

Some commonly prescribed narcotics
 MORPHINE
 OXYCODONE (Percodan)
 MEPERIDINE (Demoral)
 CODEINE
 HYDROCODONE
 D-PROPOXYPHENE (Darvon)
 PENTAZOCINE (Talvin)

Narcotic/acetominophen combination:
1. CODEINE (30mg) and ACETAMINOPHEN (300mg) (Tylenol #3):
       Prn for pain
       Up to 12 tab qd – common Rx for sever ocular pain
       Remember that ACETAMINOPHEN has no anti-inflammatory properties
2. HYDROCODONE and ACETAMINOPHEN (Vicodin)
3. DARVON and ACETAMINOPHEN (Davocet)
4. PERCODAN and ACETAMINOPHEN (Percocet)

**Tylenol #3 is probably the most commonly prescribed medicine for severe pain in eye care.




NON-Narcotic Pain Control Medication
TRAMDOL (Ultram) 50mg, 100mg.
       Caution in patients taking anti-convulsive medications and MAO inhibitors. Recently highlighted in a
number of optometric publications. Not a controlled substance but effective in pain control.

CYCLOPLEGICS AND MYDRIATICS
Introductory Comments: The relative contraindications with all dilating drops is narrow angles.

Parasympatholytics

1. ATROPINE
      Indications
      a. Diagnosis: high hyperopia in children </= 5 yrs
      b. Treatment:
          Cycloplegia in very severe anterior uveitis
          Used to break down synechiae
      Contraindications:
      a. Down’s syndrome patient
      b. Lightly pigmented patient
      Adverse effects: CNS ATROPINE toxicity (fever, flush, and delirium)
      Dosage:
      a. 1% sol tid x 3 days before exam
      b. bid – tid  cycloplegia for severe iritis
      Duration of effect:
      a. Mydriasis: 8 – 10 days
                                                                                                        36


        b. Cycloplegia: 10 – 18 days

2. SCOPOLAMINE
      Indications: ATROPINE-sensitive patients requiring full cycloplegia
      Adverse effects: ATROPINE-like CNS toxicity
      Dosage:
      a. 0.25% 1 – 2 gtts, 15 – 20 min apart  cycloplegia exam
      b. 0.25% gtt tid  anterior uveitis
      Duration of effect: cycloplegia lasts 5 – 7 days, maximum at 1 hr.

3. HOMATROPINES
     Indications:
     a. Cycloplegia in moderate acute iritis
     b. Pupil dilation and cycloplegia for retinal examination / refraction
     Dosage:
     a. 5% sol bid  anterior uveitis
     b. 5% sol 1 – 2 gtts, 5 min apart  cycloplegia / retinal exam
     Duration of effect:
     a. Mydriasis: 12 – 24 hrs
     b. Cycloplegia: up to 2 days, maximum at 1 – 2 hrs

**Homatropine and scopolamine are the most commonly used cycloplegics for iritis treatment.

4. CYCLOPENTOLATE
      Indications:
      a. Cycloplegic refraction in children > 5 yrs old
      b. Cycloplegia in mild iritis (corneal abrasion)
      Adverse effects: CNS toxicity, especially with 2%
      Dosage: 0.5 – 1.0% 2gtts, 10 min apart
      Duration of effect: cycloplegia lasts 8 – 24 hrs, maximum in 20 – 45 min

5. TROPICAMIDE
      Indications: routine pupil dilation only

**Tropicamide is quite a mild cycloplegic. So, it is not appropriate for use in uveitis treatment in almost
every case.


Sympathominetics:

1. PHENYLEPHRINE 2.5%, 10%
      Indications:
      a. Routine pupil dilation
      b. 10%  advocated by some for breaking posterior synechiae
      c. 2.5%  episcleritis diagnosis
      Adverse effects: increased pressure and pulse; use caution in patients with cardiovascular disease,
      especially with 10% concentration.
      Dilation max/ duration: 20min/2 hrs; inappropriate selection for iritis without a cycloplegia

2. HYDROXYAMPHETAMINE 1% (Paradrine)
      Indications:
      a. Routine pupil dilation – increased safety in narrow angles
      b. Diagnosis of Horner’s pupil
      Dilation max/ duration: 40 min

3. COCAINE 10%
     Indications:
     a. Diagnosis of Horner’s pupil
     b. Strong topical anesthesia
                                                                                                           37


        Dilation max/ duration: 20 min/ 2 hrs


MISCELLANEOUS THERAPEUTIC AND DIAGNOSTIC AGENTS:

1. ACETYCYSTEINE 2 and 5% sol (Mucomyst)
      a. Mucolytic: breaks down mucous
      b. Indications: filamentous keratitis, GPC, Vernal keratoconjunctivitis

2. SODIUM FLUORESCEIN 2%
      Reveals corneal epithelial defects.
          Seidel Test: bright green “river” indicates aqueous leak (surgical wound leak or globe
             perforation).
          Jones Test: presence of dye in nasal mucous after administration to the eye implies an open
             lacrimal system
          TBUT: Less than 10 sec implies insufficient tear film.
          Sodium Fluorescein: 5, 10, and 25% IV is injected for retinal fluorescein angiography.

3. ROSE BENGAL 1%
     a. Stains so-called devitalized (sick) cells
     b. Beneficial in keratitis sicca, herpes simplex keratitis, SLK

4. EDROPHONIUM (Tensilon)
      a. 2mg IV followed by 8 mg 45 sec later if no response
      b. Diagnostic test for myasthenia gravis (raises the lid temporarily if a patient has myasthenia-induced
         ptosis).
                                                                                                           38


SURIGICAL ADJUNCTS:

1. SODIUM HYALURONATE (Healon)
      Viscoelastic used to maintain anterior chamber in surgery; also used for dry eyes occasionally. If not
      completely removed during surgery, IOP can stay elevated for a couple of days.

2. EDTA 0.35%
      Chelates (binds and removes) calcium from Bowman’s membrane.               Used as treatment for band
      keratopathy.

3. ETHOXZOLAMIDE (Cardrase, Ethamide)
      CAI / diuretic used in treatment glaucoma.

4. AMINOCAPROIC ACID
      Antifibrinolytic systemically administered to treat serious hyphemas.

5. VANCOMYCIN
      Antibiotic of choice to treat endophthalmitis. It is currently the only antibiotic that has no microbial
      resistance.


OCULAR SIDE EFFECTS OF SELECTED SYSTEMIC MEDICINES:

Comments: There are some systemic topics that you need to know for patient care. In particular, some drugs
have common or interesting ocular effects. We list a number of important ones below.

1. ANTIMALARIALS (Chloroquine, Plaquenil)
      Bull’s eye maculopathy                    Optic atrophy
      Ptosis                                    EOM nystagmus and paralysis
      “Vortex” keratopathy                      Anterior and posterior subcapsular cataracts
      Retinal edema                             Vasoconstriction

2. ANTIHISTAMINES
      Reduced tear secretion
      Pupillary dilation

3. ORAL CONTRACEPTIVES
     Reduced lacrimation                        Lens-induced myopia
     EOM paralysis                              Corneal edema
     Decreased IOP                              Retinal vascular occlusion
     Optic neuritis                             Color vision defects
     Papilledema 2 to orbital pseudotumor

4. DIGITALIS (Digoxin)
      Dyschromatopsia (“yellow vision”)
      Constricted VF                            Scotomata
      Diplopia                                  Decreased IOP
      Retrobulbar neuritis                      Mydriasis

5. BETA – BLOCKERS and DIURETICS
      Reduced IOP

6. CORTICOSTEROIDS
     Increased IOP                              Posterior subcapsular cataract
     Exophthamos                                Ptosis
     Diplopia                                   Corneal edema
     Conj hemorrhage                            Retinal edema
     Dyschromatopsia                            Papilledema 2 to pseudotumor
     Toxic amblyopia                            Myopia
                                                                                           39


       Mydriasis

7. NSAIDS
      Vortex keratopathy
      Macular pigment dusting with Indomethacin

8. PHENOTHIAZINES (CHLORPROMAZINE, Thorazine)
      Lens deposits                         Decreased lacrimation
      Discolored conj and sclera            Decreased accommodation
      Miosis
      Descemet’s and endothelial pigmented corneal deposits

9. LITHIUM CARBONATE
      Cycloplegia                            Decreased lacrimation
      Transient scotoma


MISCELLANEOUS SYSTEMIC MEDICINES:

1. EPINEPHRINE (Adrenalin, Primatine Mist)
       Short acting adrenergic for treating asthma and anaphylaxis
       Used in injectables to increase vascular absorption
       Increases heart rate and blood pressure

2. ALBUTEROL (Proventil, Tentolin), TERBUTALINE (Brethaire), METAPROTERENOL (Alupent)
       Beta-agonist
       Used in treatment of asthma

3. THEOPHYLLINE (Theo-Dur)
       Bronchodilator
       Used in chronic treatment of asthma and other pulmonary disorders

4. DIAZAPAM (Valium), CHLORDIAZEPOXIDE (Librium), ALPRAZOLAM (Xanax), BUSPIRONE (BuSpar)
       Anti-anxiety medications, common prescribed

5. IMIPRAMINE (Tofranil), AMITRIPTYLINE (Elavil)
        Tricyclic antidepressants, commonly prescribed

6. FLUOXETINE (Prozac)**
       Antidepressants, most commonly prescribed in the country

7. PHENELZINE (Nardil), TRANYLCYPROMINE (Parnate)**
       MAO inhibitors
       Used in treatment of depression
       Do not use sympathomimetic (PHENYLEPHRINE) with pts on these medicines

8. HYDROCHLOROTHIAZIDE, FUROSEMIDE (Lasix)
       Diuretics
       Used in treatment of hypertension

9. PROPRANOLOL (Inderal), NADOLOL (Corgard)
       Non-selective beta-blockers
       Used in treatment of hypertension

10. METOPRALOL (Lopressor), ATENOLOL (Tenormin)
       Cardioselective beta-blockers
       Used in treatment of hypertension
                                                                                                              40


11. CATOPRIL (Capoten), ENALAPRIL (Vasotec), ISINOPRIL (Zestril)
        Angiotensin converting enzyme (ACE) inhibitors
        Used in treatment of hypertension

12. VERAPAMIL (Calan), DILTIAZEM (Cardiazem), NIFEDIPINE (Procardia)
        Calcium-channel blockers
        Used in treatment of hypertension

13. CHOLESTYRAMINE (Questran), COLESTIPOL (Colestid), LOVESTATIN (Mevacor), NIACIN
       Used in treatment of high cholesterol

14. CARBAMAZEPINE (Tegretol), PHENYTOIN (Dilantin), VALPROATE (Depakote), ETHOXSUXIMIDE
    (Zarontin)
         Anti-seizure medicines

15. METOCLOPAMIDE (Reglan), ERGOTAMINE (Cafergot)
       Used in treatment of migraine


    CHAPTER 4: CONDITIONS REQUIRING LESS DETAILED KNOWLEDGE

LID CONDITIONS:

LID BURNS
     Diagnosis: History of injury with chemical or heat
     Treatment: cold packs, topical antibiotics and sterile dressings; eye itself must be examined

LID CONTUSIONS
     Diagnosis: history/signs of trauma (black eye)
     Treatment: cold packs, rule out signs of more essential trauma (blow-out fracture or orbital rim fracture

LID LACERATIONS
     Diagnosis: history of trauma
     Treatment: surgical repair soon, unless edema present; keep eye lubricated

TRICHIASIS
    Diagnosis: pt reports foreign body sensation; SLE shows misdirected lashes abrading the cornea/conj;
      often results from blepharitis
    Treatment: surgery by cautery, cryotherapy, electrolysis/epilation, treatment underlying blepharitis

MYOKYMIA
   Diagnosis: lid twitching reported by pt or observed by doctor
   Treatment: oral antihistamine or reassurance

ESSENTIAL BLEPHAROSPASM
    Diagnosis: involuntary muscle contraction of the orbicular is, bilateral, elderly; possibly psychogenic in
     nature
    Treatment: OCULINUM (botulinum toxin) injection, psychotherapy

MYASTHENIA GRAVIS
   Diagnosis: ptosis and diplopia often initial manifestation, Tensilon (ENDROPHONIUM) given IV
     reverses this ptosis temporarily and confirms Diagnosis fatigue is consistent sign
   Treatment: PROSTIGMINE or PYRIDOSTIGMINE ptosis surgery

BASAL CELL CARCINOMA
    Diagnosis: most common eyelid tumor; nodular, pearly surface with small vessels, and usually ulcerated
      center
    Treatment: surgical excision with histological confirmation (biopsy)
                                                                                                             41



SEBACEOUS CELL CARCINOMA
    Diagnosis: from meibomian glands; malignant; growth may mimic chalazion / chronic blepharitis; in
     cases of recurrent chalazia, this tumor must be suspected
    Treatment: surgery

SQAMOUS CELL CARCINOMA
    Diagnosis: in older pt, looks like benign keratocanthoma
    Treatment: surgical excision and pathological report to be certain that all of the tumor is removed

DERMOID
    Diagnosis: smooth, cyst-like benign tumor containing several anatomical elements (hair, sebaceous
     glands, etc.); usually at lateral canthus
    Treatment: excise if symptomatic

MALIGNANT MELANOMA
    Diagnosis: uncommon, potentially metastasizing tumors; usually arise from nevi; high death rate, extend
      deep
    Treatment: surgery

SUDERIFEROUS CYST
    Diagnosis: clear lid cyst
    Treatment: surgery, lancing, minor

SEBACEOUS CYST
    Diagnosis: can be quite large; non-clear cyst
    Treatment: surgery

VERRUCA VULGARIS
    Diagnosis: warts
    Treatment: dichloroacetic acid (aka bichloroacetic acid); cautery topically applied to lesions

MOLLUSCUM CONTAGIOUSUM
   Diagnosis: produced by virus; small, umbilicated lid lesion; can irritate conj / cornea through the virus
     shedding from the lesion; often multiple lesions
   Treatment: excision / cautery

XANTHELASMA
    Diagnosis: yellowish lipid deposits in the nasal and lower lids due to high lipids in the blood (think high
     blood cholesterol level)
    Treatment: surgical excision

HEMANGIOMA
    Diagnosis: usually present at birth; benign purple vascular skin tumor
    Treatment: surgery

KERATOACANTHOMA
    Diagnosis: benign skin lesion in older men in sun-exposed area with a keratin-filled crater
    Treatment: resolve on own / surgical excision

PAPILLOMA
    Descriptive form of a nonspecified skin bump or lump shaped like a papilla

SENILE KERATOSIS
    Skin lesion related to sun exposure may be precancerous; flat scaly lesion also called actinic keratosis.


                                                  TUMOR SUMMARY
                                                                                                       42


       BENIGN                                      MALIGNANT
       papillomas                                  basal cell carcinoma
       keratoses                                   squamous cell carcinoma
       keratoacanthoma                             malignant melanoma
       nevi                                        sebaceous cell carcinoma
       epithelial cyst
       sebaceous cysts
       sudoriferous cysts
       molluscum contagiosum
       xanthelasma
       hemangioma
       dermoid



CONJUNCTIVAL CONDITIONS:

OPHTHALMIA NEONATORM
    Diagnosis:     child born with conjunctivitis, usually due to gonococci / chlamydia / staph /
     pneumococci / Haemophilus / Herpes simplex
         a. SILVER NITRATE prophylaxis
         b. gonococcal (2 – 3 days onset after birth) and chlamydial (5 – 12 days after birth) infection
            most common
    Treatment: gonococcal infection: CEPHRIAXONE IM / KENAMYCIN IM; chlamydial infection:
     ERYTHROMYCIN orally (not TETRACYCLINE)

CONJUNCTIVAL BURNS
   Diagnosis: history
   Treatment: immediate and profuse irrigation; cold compresses; atropine; antibiotic as required; later
     may require surgery due to scarring

CONJUNCTIVAL LACERATION
   Diagnosis: history / observe with FLUORESCEIN
   Treatment: antibiotic ointment, not sutures

CONJUNCTIVAL FOREIGN BODIES
   Diagnosis: history / observe with FLUORESCEIN
   Treatment: removal in these order 1) lavage 2) swab 3) spud 4) antibiotic ung after removal

CORNEAL CONDITIONS

ABMD (ANTERIOR BASEMENT MEMBRANE DYSTROPHY / EPITHEAL BASEMENT MEMBRANE
DYSTROPHY / MAP-DOT-FINGERPRINT DYSTROPHY / COGAN'S)
    Diagnostic:    anterior corneal "debris" and cysts in pupil area recurrent erosions
    Treatment:
     1. Muro 128 gtts and (5% SODIUM CHLORIDE)
     2. corneal puncturing
     3. excimer laser corneal resurfacing
     4. erosion treatment involves pressure and patching
     5. mechanical removal of loose tissue
     6. ointment at bedtime for a few month
     7. therapeutic SCL helps

FUCH'S DYSTROPHY
    Diagnostic:      starts age 30-40, women, corneal guttata seen on SLE, corneal edema results; can be
      associated with glaucoma or iris atrophy
    Treatment:
      1. Muro 128 gtts and ung (5% SODIUM CHLORIDE)
      2. corneal transplant
                                                                                                              43


        3. no CL wear

BULLOUS KERATOPATHY
    Diagnostic:       corneal epithelial edema (due to poor endothelial function); bullae (epithelial cysts) are
     painful on rupturing; history of Fuch’s dystrophy / cataract surgery.
    Treatment:
     1. bandage SCL
     2. corneal transplant (penetrating keratoplasty)

BAND KERATOPATHY
    Diagnostic:      calcium deposited on interpalpebral anterior corneal; may indicate uveitis as child
      metabolic diseases / JRA may be a cause.
    Treatment:
      1. removal of corneal epithelium with irrigation w/ EDTA
      2. excimer laser removal of calcium (PTK).


DRY EYE SYNDROME
    Diagnostic:     many etiologies (drugs, age, lupus, Sjogren’s, etc); results in chronic, low-grade ocular
      irritation.
    Treatment:
      1. tear replacements with AT
      2. Ocuserts (sustained-release form of treatment)
      3. SCL used as bandage
      4. Punctal occlusion
      5. Moist chambers

SJOGREN'S DISEASE
    Diagnostic:  keratitis sicca (dry eye), Serostoma (dry mouth), arthritis (joint pain)
    Treatment:   as above for DES

PHYLYCTENULE
    Diagnostic:     allergic reaction producing a conjunctival or corneal nodule that spontaneously heals;
     generally due to staph or tuberculosis
    Treatment:      topical steroid

CORNEAL FOREIGN BODIES
   Diagnostic:      history of trauma; SLE with fluorescein
   Treatment:
     1. topical anesthesia and removal (needle, spud) and rust ring removal (needle / Alger brush)
     2. mild cycloplegia (ie CYCLOPENTOLATE 1%)
     3. spectrum antibiotic ung (ie GENTAMYCIN)
     4. pressure patch
     5. follow-up in 1 day

CORNEAL ABRASIONS
     Diagnostic:      history; severe pain; lacrimation; blepharospasm (examine after topical anesthesia);
        add FLUORESCEIN; look under upper lid for foreign body
     Treatment:        antibiotic ung; cycloplegia; pressure patch; RTC 1 day
Note about patching: several recent studies have explored whether or not patching should be done with
abrasions. The consensus seems to be that in the usual case no patching need be done as healing time is not
affected (and may be shorter). The traditional treatment is to patch, however.

CORNEAL BURNS
   Diagnostic:      history
   Treatment:
     1. Copious irrigation if chemical, referral to emergency room
     2. Cycloplegia
                                                                                                                   44


        3.   Pain meds po
        4.   Topical antibiotic ung if mild burn
        5.   admit to hospital if mod / severe
        6.   Check for IOP increases
        7.   Topical steroids to reduce scarring


LACRIMAL SYSTEM CONDITIONS:

DACRYOCYSTITIS
    Diagnostic:      infection of lacrimal sac; unilateral; obstructed nasolacrimal duct; risk of orbital cellulitis;
     tearing, discharge, acute onset of pain, swelling, tenderness, pus can be expressed on palpation of sac;
     usually caused by staph / beta-hemolytic strep
    Treatment:
     1. cure is surgery: DCR (dacryocystorhirrostomy)
     2. Some relief with systemic and topical antibiotic
     3. Infants: resolves on own
              a. If >= 6 months  lacrimal probing
              b. If < 6 months  topical antibiotics and lacrimal sac massage

CANALICULITIS
    Diagnostic:       chronic conjunctivitis with canalicular inflammation; caused by fungus Actinomyces
    Treatment:
      1. surgical removal of granules or
      2. Expression of granules or
      3. Irrigation with penicillin solution

PUNCTAL STENOSIS
    Diagnostic: obstruction may be seen from conj shrinkage
    Treatment:  dilation of the punctum


SCLERA / EPISCLERA:

SIMPLE EPISCLERITIS
    Diagnostic:     localized inflammation of episclera (tissue over sclera), redness, pain, photophobia,
      tenderness, and lacrimation, defined location (usually described as triangular)
    Treatment:      benign; lasts 1 –2 wks; topical steroid may helps

NODULAR EPISCLERITIS
   Diagnostic:   has nodule on episclera
   Treatment:    steroid may not be as helpful

DIFFUSE ANTERIOR SCLERITIS
    Diagnostic:      significant pain (deep, “boring” pain); threatens vision; women > men
      tends to be progressive; assoc with rheumatoid arthritis, herpes zoster, and gout

NECROTIZING SCLERITIS
    Diagnostic:     more severe with scleral melting; vascular closure; staphyloma formation; 29% patients
     dead within 5 yrs

POSTERIOR SCLERITIS
    Diagnostic:    pain, reduced VA, exudative retinal detachment, choroidal detachment, retinal edema
    Treatment:
     1. Topical steroid with systemic NSAIDs
     2. Systemic steroids
     3. Immunosuppressive drugs
     4. Thinned sclera can be supported with surgical graft of donor sclera / other material
                                                                                                            45



ORBIT:

ORBITAL CELLULITIS
   Diagnostic:       most common cause of ptosis in children, develops rapidly; must be treated promptly;
      edema, hyperemia, erythema, pain, deep orbital chemosis, proptosis, decreased VA, limited eye
      movements; cavernous sinus involvement may cause CN involvement
   Treatment:
      1. Starts before causative organism found
      2. Nasal, conjunctiva, blood cultures
      3. Ampicillin / amoxicillin
      4. Hot compresses to localize infection
      5. Sinus drainage may be necessary

ORBITAL PSEUDOTUMOR
   Diagnostic:  diffuse orbital inflammation, rapid onset of pain, unilateral
   Treatment:   systemic steriods

BLOW-OUT FRACTURE
    Diagnostic:      history trauma; endophthalmos (determined by exophthalmometry); if severe or diplopia,
     limitation of movements with forced duction; decreased sensitivity of infraorbital nerve; Waters view X-
     ray / CT scan
    Treatment:
     1. Wait 1 –2 wks for resolution of edema to evaluate need for surgery
     2. Persistent diplopia, enophthalmos, large fracture of orbital floor

SURGERY:

CATARACT SURGERY
    Diagnostic:    reduced VA; cataract on examination
    Treatment:
     1. Surgery if VA reduced and improves with surgery (indicated by clinical exam, PAM, interferometry)
     2. No contraindication to surgery
     3. Postoperative meds include antibiotic and steroid (for approx a month)

IATROGENTIC IRITIS AND UGH (uveitis, glaucoma, hyphema) SYNDROME
    Diagnostic:     uveitis, glaucoma, hyphema, or just iritis can occur after intraocular surgery
    Treatment:
      1. Treat as condition warrants
      2. Uveitis  steroid
      3. Prophylaxis         antibiotic
      4. Increased IOP  IOP reducing agent
      5. Examine for endophthalmitis: worsening iritis, hypopyon, upper lid edema, discomfort. These all
         might signal an infection inside the eye
      6. Usually post-op follow-up: 1 day, 1 week, 1 month, 3 months

SYSTEMIC DRUGS AFFECTING THE PERIPHERY
    Diagnostic:      dilated / constricted pupil with history of drug use
    Treatment:
     1. These can dilate the pupils
     2. Tricyclic antidepressants
     3. Phenothiazine antipsychotics
     4. Antihistamine
     5. Anticholinergics

OCULINUM
   Diagnostic:      paralyzes the muscle that it’s injected into, straighten eyes out (temporary), stretching
      and contracting appropriate muscles to change balance of forces to allow alignment, used for
      blepharospasms; expose to botulism toxic
                                                                                                             46


PRK
       Post-operative PRK management usually involves:
        1. Bandage CL until cornea re-epithelializes
        2. Topical antibiotic gtts until corneal re-epitheliarizes
        3. Topical corticosteroid gtts
        4. Topical NSAID gtts
       The drops are continued until the desired refraction is obtained. The drop dosage is altered based on
        the healing response. LASIK is much simpler with only an antibiotic on the immediate post-op period.



INTERNAL OCULAR INFECTION / INFLAMMATION:

TOXOPLASMOSIS
    Diagnostic:      domesticated cats as host, pregnant women can transmit to fetus, retinal and choroid
     inflammation with floaters, blurred vision / photophobia, punched-out retinal lesions, can recur at borders
     of lesions
    Treatment:       PYRIMETHAMINE and SULFADIAZINE / CLINDAMYCIN and TRISULFAPYRIMIDINE
              Ocular uveitis  steroids and cycloplegia

POHS ( Presumed Ocular Histoplasmosis Syndrome)
    Diagnostic:        endemic area (primarily river valleys), inflammation of choroid (no vitritis / uveitis),
       positive histoplasmosis skin test, Classic triad:
                    1. Yellow-white punched-out spots
                    2. Macular gray-green CNVM (Choroidal neovascular membrane)
                    3. Optic atrophy / scarring (sometimes with nodule / heme)
    Treatment:
       1. CNVM           laser
       2. No effective antifungal treatment

TOXOCARA
    Diagnostic:      granuloma (elevations) on retina / chronic endophalmitis; usually in children; redness,
     blurred vision, white pupil; ELISA test for toxocara; vector: cat / dog
    Treatment:
     1. PREDNISOLONE injection around the eye, or
     2. Systemic steroids

SARCOID
    Diagnostic:     unknown cause; chronic uveitis (anterior or posterior), posterior has retinal exudates
     (“candle wax drippings”) and perivasculitis
    Treatment:
     1. corticosteroid (system and/or topical)
     2. Workups:
             i.  Chest X-ray
            ii.  Serum angiotensin converting enzyme (ACE)
           iii.  PPD with anergy panel
           iv.   Gallium scan
AIDS
    Diagnostic:     wt loss, fever, diarrhea, swollen lymph nodes, encephalopathy
     1. Ocular:
             i.  Cotton-wool spots, hemorrhages, conj vessels anormalities
            ii.  CMV infection of retina (hemorrhagic necrosis of retina w/ art occlusions)
           iii.  Optic disc edema
           iv.   Herpes simplex retinitis (as arteriolar occlusion w/ simplex encephalitis)
            v.   Toxoplasma choroidretinitis (as vitritis)
           vi.   Herpes zoster usually in elderly, but if in young children, then think AIDS
    Treatment:
     1. CMV GANCICLOVIR
     2. Herpes  ACYCLOVIR
                                                                                                               47


        3. Infection  AZT (ZIDOVUDINE)
        4. New protease inhibitor therapies have revolutionalized treatment of AIDS and significantly reduced
           morbidity and mortality.


SYSTEMIC CONSIDERATIONS:

CRVO (CENTRAL RETINAL VEIN OCCLUSION)
    Diagnostic:       elderly, hypertension, diabetes; tortuous ret. Veins, retinal + macular edema w/ massive
      hemorrhages; attenuated arteries; 2 neovascular glaucoma may develop
    Treatment: argon laser pan retinal photocoagulation (PRP) to reduce chance of neovascular glaucoma;
      prognosis for vision: poor

HYPERTENSION AND ARTERIOSCLEROTIC RETINOPATHY
    Diagnostic:    retinal artery reflection becomes wider; arteriosclerosis; copper   /   silver          wiring
     appearance; cotton wool spots, hemorrhages, exudates, disc edema
    Treatment:     retinal fluorescein angiography indicates laser treatment may be needed

BRVO (BRANCH RETINAL VEIN OCCLUSION)
    Diagnostic: 2 to venous occlusion; isolated area of retinal hemorrhage
    Treatment:  may self-limit / need laser photocoagulation

CRAO (CENTRAL RETINAL ARTERY OCCLUSION)
    Diagnostic:       total retinal swelling; retinal pallor usually 2 to emboli from carotid artery; macula has
      “cherry red spot”
    Treatment:
      1. Blood flow by dilation vessels (breathing into bag to  CO2 levels)
      2. Globe massage
      3. IV ACETAZOLAMIDE / paracentesis to IOP
      4. Nothing is very effective; systemic work-up needed

**CRAO and alkali burns are the two stat ocular emergencies.

BRAO (BRANCH RETINAL ARTERY OCCLUSION)
    Diagnostic: only a sector of retina effected as in CRAO
    Treatment:  same as with CRAO

BDR (BACKGROUND DIABETIC RETINOPATHY)
    Diagnostic:     diabetes history; micro aneurism, dilated veins, small flame / dot and blot hemes,
      exudates; may or may not have macular edema
    Treatment:      control of diabetes, laser treatment for CSME

PDR (PROLIFERATIVE DIABETIC RETINOPATHY)
    Diagnostic:  revascularization, vitreous hemorrhage, tractional retinal detachment
    Treatment:   argon laser panretinal photocoagulation (PRP), vitreoretinal surgery


FUNDUS CONDITIONS:

CLINICALLY SIGNIFICANT MACULAR EDEMA
    Diagnostic:      caused by DM; hard exudates within 500m of the fovea with macular edema (for
      reference, the optic nerve head is about 1.5 mm or 1500m in diameters, thus 500m is 1/3 of disc
      diameter)
    Treatment:       focal / grid laser depending on fluoroscein angiography

ARMD (AGE-RELATED MACULAR EDEMA)
    Diagnostic:  Dry  drusen and RPE atrophy
                  Wet  subretinal neovascularization assoc. w/ age
                                                                                                                   48


       Treatment:
        1. Dry: monitor
        2. Wet: fluorescein angiography and treatment with laser photocoagulation

PAPILLEDEMA
    Diagnostic:     swollen nerve on ophthalmoscopy 2 to  intracranial pressures (tumor,         trauma,
      malignant HTN, benign); peripapillary edema, hemorrhages, cotton-wool spots; enlarged blind spot
    Treatment:      CT / MRI scan

AION (ANTERIOR ISCHEMIC OPTIC NEUROPATHY / TEMPORAL ARTERITIS / GCA)
    Diagnostic:        acute disc swelling with a few hemes assoc w/ temporal arteritis / arteriosclerosis; acute
      VA / altitudinal VF loss; temporal arteritis in elderly; pain on chewing / over temporal artery; weight loss;
      malaise, aches and pains, fever;  ESR (erythrocyte sedimentation rate)
    Treatment:         ESR status, steroid if elevated, no treatment otherwise


OPTIC NEUROPATHY
    Diagnostic:      inflammation of optic nerve; marked  VA; no ophthamoscopic signs; most commonly
      assoc with multiple sclerosis (MS); temporary / permanent
    Treatment:       steroids often shorten course



CYSTOID MACULAR EDEMA
    Diagnostic:         VA; post-cataract surgery (2 – 6 wks after surgery is the peak incidence); retinal
      vascular leakage (vein occlusion, diabetes); inflammation from “macular irritation” (epiretinal membrane,
      vitreous traction, primary macular inflammatory disease; fluid fills in separate, intraretinal cysts or blisters
      surrounding fovea; perifoveal fluorescence on angiography diagnostic
    Treatment:         topical steroids, Injectable steroids, topical Voltaren (KETOROLAC) or oral NSAID

CHAPTER 5: CONDITIONS REQUIRING LEAST DETAILED KNOWLEDGE

Although very important, these items are of lesser significance because they are rarely part of primary eye care
or are simple to treat.

AMPPE
   Acute Multifocal Placoid Pigment Epithellopathy
   Grey-white “plaque – like” lesions at the RPE level in the posterior pole
   Young women; spontaneously resolves; scotoma

ANGLE RECESSION
    Post-trauma to the eye
    The anterior chamber configuration can change in some patients to produce glaucoma many yrs after
      the trauma

BLEPHAROCHALSIS
    In young people, skin folds in lids from loss of elasticity 2 to chronic swelling
    Treatment with surgery

CHLOASMA
    Blotchy brown skin lesions on face in women 2 to pregnancy / oral contraceptives

CN III PARESIS (THIRD NERVE PALSY)
    Exotropia & hypotropia (eye points down and out a lot)
    Pupil affected
    Neurological problem

COLOBOMA
                                                                                                       49


       Congenital absence of part of the eye
       Commonly involves upper lid / infero-nasal iris / optic nerve

CONCRETIONS
   Conjunctival cysts with yellow particles in cul-de-sac
   If symptomatic, excised and antibiotic

CONGENITAL PTOSIS
   Drooping of eyelid at birth
   Treatment with surgery

DERMATOCHALASIS
    Age – related upper lid laxitiy and droopiness
    Treatment with surgery

DISTICHIASIS
    Congenital extra row of lashes posterior to normal lashes in meibomian orifices

EALES DISEASE
    Retinal vessel inflammation of unknown cause that may cause vitreous hemorrhage & macular edema

ECTOPIA LENTIS
    Dislocation of crystalline lens 2 to poor zonule structure, usually from Marfan’s syndrome

ECTROPION
    Outward drooping of lower lid & lashes 2 aging / trauma
    Treatment: lubricant / surgery

ENTROPION
    Inward turning of lid & lashes 2 aging / trauma
    Treatment: taping / surgery

EPIRETINAL MEMBRANE / CELLOPHANE MACULOPATHY
    Membrane over macula occuring in elderly / post – intraocular surgery
    Can be removed with surgery

GYRATE ATROPHY
    Choroidal atrophy with scalloped edges
    Myopia,  night vision,  blood ornithine levels

LYMPHANGECTASIA
    Diluted lymph channels; looks like clear conjunctiva cysts
    If symptomatic: can be drained by lancing

MACULAR HOLES
   Idiopathic
   Elderly; VA 20/200 – 400
   New surgical procedures for closing

MADAROSIS
   Loss of lashes, usually 2 to blepharitis

MEWDS
   Multiple Evanescent White Dot Syndrome
   Idiopathic & self resolution
   Young women; dots at RPE level

NEVUS
                                                                                                              50


       Colored skin / fundus lesion with solid coloration
       May be pre-malignant

NEVUS OF OTA
    Congenital; Asians
    Unilateral, blue-green scleral pigment affects uvea
    No treatment required

ORBITAL TUMORS
   Generally cause proptosis (measure with exophthalmometry) due to taking up space and pushing the
      eye out of the orbit

OPTIC PIT
    Congenital
    Defect of optic nerve with scotoma & macular edema

PINGUECULA
    Elastic tissue & hyaline on conjunctiva 2 to UV exposure

PITUITATY LESIONS
    Most common brain tumor
    Usually young adults
    Superior – temporal VF loss per eye

POLIOSIS
    Depigment of lashes, usually 2 to blepharitis

PTERYGIUM
    Degeneration of corneal epithelium and Bowman (replaced with elastic tissue & hyaline)
    Related to UV; treatment with surgery

RETINAL DETACHMENT
    Fluid between retina & RPE, usually 2 to retinal tear; grey opaque appearing retina and perhaps retinal
      folds; retinal movement on eye movement; VF loss
    Treatment: laser photocoagulation / cryo to seal tear

SRVNV
    Subretinal Neovascularization
    Usually 2 to ARMD, histoplasmosis, angioid streaks

TIA / STROKE
     Transient Ischemic Attack
     Temporary loss of vision from occlusion of vessel in brain or eye from carotid artery atherosclerosis
     Stroke is permanent loss

TOXIC CATARACT
    Cataract 2 to medication / radiation (usually PSC) or metal in eye (copper creates sunflower)

VITILIGO
     Localized loss of skin pigment

								
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