Liana Al-Labadi, O.D.

If you hear hoof beats, think horses

—not zebras

Case 4: The Irritated Eye 19yo PM c/o red irritating eyes

Frequency: Constantly (all the time, everyday) Onset: 1 month ago Location: Both eyes Duration: 6 months ago had a similar problem and was

given eye drops which made things better Associated Factors:

Any tearing? Any Discharge? YES- Notices yellow discharge once in a while

Any Itch? YES- my eyes itch all the time and I’m always rubbing them

Any burning sensation? Yes Are your eyes sticky? Crusty? Watery? Not sure they’re just

extremely irritating Have you been sick lately? No Any pain? No- more irritation than pain Do you feel your eyes have become more sensitive to light? Yes Do you think anything has triggered this? Not sure Has you vision been affected at all? No my vision is fine Are you a CL wearer? No

Relief: Tried using AT but not noticing any improvement Severity: 8/10 itch & irritation

DIFFERENTIAL DIAGNOSIS????

POH: Negative for HA, DIPL, asthenopia, surgery, trauma, pain,

F&F6 months ago was diagnosed with some allergy condition

of the eyeLEE: 6 months ago by Dr. Mazen Khowaira FOH: Negative for AMD, DR, Glc, CatLPE: Never had onePMH: Negative for DM, HTN, Cancer, NeuroFMH: Negative for DM, HTN, Cancer, NeuroMED: None Allg: NKDA; No seasonal allergiesSH: playing sports; No known exposure to

anyone with infectious eye diseaseOccupation: StudentNo alcohol consumption Smokes Argeeleh occasionally

Case 4: The Irritated Eye

Entrance Testing????

Entrance Testing: DVA (s): 20/20 OD; 20/20 OS Motility: S&F OD, OS Confrontations: Full OD, OS Pupils: 4mm/4mm RRL OD, OS; No APD

Minimal light sensitivity noted No pain on eye movement No DIPL

No PAN

Case 4: The Irritated Eye

Additional Testing????

SLE: L/L:

Trace papillary reaction OD, OS No mucous debris OD, OS

Conj: Tr-1+ temporal para-limbal injection OD,OS Small temporal calcified concretions/infiltrates

OD,OS K: Clear OD, OS Iris: Flat & brown OD, OS AC: No cell & no flare/ D&Q OD, OS Lens: Clear OD, OS (undilated)

IOP: ????

Case 4: The Irritated Eye

Case 4: The Irritated Eye

http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Vernal-Keratoconjunctivitis.html

http://mednt.jp/index.php/trantas+dots

DIFFERENTIAL DIAGNOSIS????

Differential Diagnosis: Atopic keratoconjunctivitis Seasonal allergic conjunctivitis Viral conjunctivitis Bacterial conjunctivitis Chlamydial and Gonococcal conjunctivitis Superior Limbic Keratoconjunctivitis (SLK of

Theodore) Toxic conjunctivitis Giant papillary conjunctivitis (associated with

foreign body or CL wear or chronic inflammation) Episcleritis or Scleritis Pterygium Phylctenulosis

Case 4: The Irritated Eye

ADDITIONAL TESTS???

FINAL DIAGNOSIS

Case 4: The Irritated Eye

Assessment: Vernal Keratoconjunctivits (VKC) OU

Plan:Begin FML ophthalmic solution QID OU x 1 week then BIDx 1 week then stopRecommend Cool Compresses OURecommen Genteal ATs PRN OU RTC in 2 weeks for F/U

At F/U consider Patnol BID OU

VKC Major Symptoms:

Ocular itching- usually severe Minor Symptoms:

Ocular burning Photophobia Tearing Redness Thick, ropy discharge Seasonal (spring/summer recurrences) History of atopy- (asthma, rhinitis, and

eczema)

VKC An allergy associated recurrent inflammatory disease Usually bilateral though asymmetry is common Two forms exist:

Tarsal VKC Limbal VKC (less common)

Epidemiology: <1% of population Males > Females

Usually seen in young boys Most common 5-20 years of age Most common in the springtime (correlating to

allergen levels) Numerous flare-ups during childhood

Predilection for warm/dry climates

VKC

Pathogenesis: The immunopathogenesis is

multifactorial. Classically it has been thought of as a

type I IgE-mediated hypersensitivity reaction It has been suggested that there is cell-

mediated Th-2 involvement.

VKC Tarsal VKC Signs:

Large conjunctival papillae under upper lid Apparent on lid eversion Usually results in pseudo-ptosis

Limbal VKC Signs: Limbal & paralimbal conjunctival injection Broad, thickened conjunctivl nodules near the

limbus with white lesions over top aka Horner-Trantas’ dots Usually there is a confluence of nodules Most commonly seen at the superior cornea-

limbus margin Usually have a mild, milky-white gelatinous

appearance Trantas’ dots= aggregates of eosinophils &

degenerated epitheloid cells

Tarsal VKC

Limbal VKC

http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Vernal-Keratoconjunctivitis.html

http://www.drmalcolmmckellar.co.nz/allergic-eye-disease/what-is-it.html

VKC Other Signs?

Corneal involvement in 50% of the cases Punctate epithelial keratitis Superficial K pannus Corneal shield ulcers

Well-delineated, sterile, gray-white infiltrate Observed in 10% of patients

VKC

Complications: (in 6% of patients) Visual loss from:

K vascularization K scars Keratoconus Steroid-induuced cataracts Steroid-induced glaucoma

VKC Treatment

4 weeks prior to allergy season begin topical treatment with: Mast cell stabilizer (i.e. cromolyn sodium 4% QID) Mast cell stabilizer/Antihistamine:

i.e. olopatadine 0.1% BID OR lodoxamide 0.1% QID) Antahistamine: (i.e. azelastine 0.05% BID)

If moderate to severe inflammation: Topical steroid (fluorometholone 0.1% to 0.25% OR

lotepredonol 0.5% OR prednisolone acetate 1% OR dexamethesone 0.1% ointment) 4-6 times a day With the appropriate tapering scheduke

Cool compresses If shield ulcer:

Topical steroid +/- topical antibiotic and cycloplegic agent

If not responding to treatment, consider cyclosporine 0.05% BID

VKC

Follow-up schedule: Every 1-3 days in the presence of a

shield ulcer Otherwise every 1-2 weeks Maintain anti-allergy drops for the

duration of the season Patients on topical steroids should be

monitored regularly Prognosis:

Poor if increased size of papillae Poor if sever bulbar /limbal VKC