Not So Trivial Pursuits: Anterior Segment Diseases

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• Not So Trivial Pursuits Anterior Segment
  Diseases

Ron Melton, OD, FAAO Randall Thomas, OD, MPH,
FAAO www.eyeupdate.com
Detroit, Michigan April 23, 2011
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Conjunctival Concretions

• Common asymptomatic finding
• Calcific bodies can become erosive
• FBS common symptom from erosive lesions
• Easily removed at slit lamp
• Anesthetic eye drops (proparacaine or Fluress)
• Phenylephrine pretreatment can minimize bleeding
• Golf club spud, needle, or instrument of choice
• Antibiotic/steroid eyedrops qid for 3-5 days

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• 12 y/o wf OS exotropia
• Tobramycin X7 day for OS redness/irritation
• No significant discharge
• SLE 1 to 2 staphylococcal build-up on lids
• 2 conj injection OS
• corneolimbal involvement 2 and 7 oclock
• stains with Fl
• A/C quiet TA 16 OU
• Internal normal OU

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Phlyctenular Keratoconjunctivitis

• Nodular inflammation of paralimbal tissues
• Mainly in children and young adults (females)
  allergic hypersensitivity response to some
  antigen to which the tissue has become sensitized
  (staphylococcal most common TB rare)
• Symptoms photophobia and FB sensation (worse in
  corneal involvement)
• Signs pinkish-white elevations fl stain
• Tx antibiotic/steroid along with lid scrubs
• If TB suspected, Tine or PPD(skin) chest x-ray

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Wilsons Disease

• AKA hepatolenticular degeneration
• Potentially fatal defect of copper metabolism
• Also decreased levels of ceruloplasmin
• Autosomal recessive presents usually ages 8-16
• Can cause a wide variety of neurological
  disorders
• Copper deposits on the periphery of Decemets
  membrane in virtually 100 of patients
• Known as Kayser-Fleischer ring
• The Kayser-Fleischer ring is pathognomonic of
  Wilsons disease

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Lisch Nodules

• Represent an iris hamartoma
• Associated with neurofibromatosis
• Seen in 90 of afflicted patients
• Characteristics elevated lesions with smooth
  contour, soft translucency, and light tan color
• DDx iris nevi

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Pseudoexfoliation Syndrome

• Increases in older age represents about 5 of
  all the glaucomas
• Seen almost exclusively in Caucasians
• If unilateral, will become bilateral over 5-10
  years
• When glaucoma is present, IOP tends to be higher
  and more difficult to control
• Whitish flakes at pupil border and lens face
• Gonioscopy looking for trabecular pigmentation
  (Sampaolesis Line)
• No systemic association not inherited

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Topical Ganciclovir

• Used systemically to treat CMV retinitis
• A new topical pro-drug for treating epithelial
  HSV
• Only acts on virally infected cells
• Used 5 x D for 4 to 6 days, then tid for 3 to 4
  more days
• Is a 0.15 ophthalmic gel-drop with BAK
• Marketed as Zirgan ophthalmic gel
• Comes in a 5 gram tube
• Marketed by BL Pharmaceuticals

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Topical Antiviral Options

• Trifluridine
• Old drug
• Indiscriminate expression
• Potentially toxic
• More frequent dosing
• Refrigerate until opened
• Thimerisol preserved
• Solution (7.5 ml bottle)
• Viroptic and generic

• Ganciclovir
• New drug
• Infected cell-specific
• Minimally toxic
• Less frequent dosing
• No refrigeration needed
• BAK preserved
• Gel (5 gram tube)
• Zirgan by BL

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Primry HSV Infection

• Vesicular eruptions on the eyelid skin and/or
  eyelid margin
• Can be limited to the skin or can also result in
  follicular conjunctivitis and/or corneal
  epithelial disease
• Treatment PO ACV 400 mg 5 x D x 1W
  PO Valtrex 500 mg tid x 1W
• Vesicles resolve without scarring

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Herpes Gladiatorum

• Occurs most commonly among young wrestlers, or in
  other sports where there is very close skin
  contact.
• First described in the 1960s NEJM
• It is an expression of HSV-I
• Lymph nodes (preauricular and/or submandibular)
  are commonly present on one or both sides
• Treated with oral antiviral for a week
• Like all HSV infections, can become recurrent in
  nature.
• Temporary isolation from sports while being
  treated is key to breaking cycle of perpetuation

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Fabry Keratopathy

• Unique corneal finding VA usually unaffected
• X-linked recessive disorder
• Looks similar to Plaquenil and and amiodarone
  keratopathy
• Seen in affected males and carrier females
• Results from deficient levels of alpha
  galactocidase A
• Males usually die age 40-50 of cardiac / renal
  disease
• Female carrier likely seen in office settings
• No ocular therapy needed / new systemic Tx!
• IV Fabrazyme q 2 weeks (by Genzyme)
• Visit www.fabrycommunity.com

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Amiodarone (Cordarone)

• Indications life-threatening arrhythmias
• Accumulates in high concentrations in tissue
• Dosage 800-1600 mg/d initially, decreased to
  400 mg/d at maintenance dose
• Ocular findings
• Corneal subepithelial microdeposits in
  verticillate pattern a constant feature
• Papillopathy possible, but uncommon
• Can be confused with non-arteritic AION

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Amiodarone- induced Optic Neuropathy Nonarteritic Anterior Ischemic Optic Neuropathy
Onset of visual loss Insidious (Months) Rapid (days to weeks)
Degree of visual loss 20/20 20/200 20/20 - NLP
Resolution of disc edema Months Weeks
Ocular involvement Usually simultaneous within weeks Rarely simultaneous
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Characteristics of Traumatic Hyphema

• High velocity - blunt trauma
• 75 males
• Clot duration - 3 days
• Rebleed rate highly variable - 5-15 average
• Children rebleed less than adults
• Angle recession is common
• Late glaucoma rare
• Vast majority recover 20/30 or better

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Traumatic Hyphema Management

• Bed rest - quiet life x 5 days
• Sleep with head elevated
• No reading - can watch TV
• Steroid dosage depends on chamber reaction
• Homatropine 5 as indicated
• Aminocaproic acid systemically (?)
• Binocular Indirect Ophthalmoscopy
• Gonioscopy in 4 weeks (not initially)

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Latisse and Skin Hyperpigmentation

• The prescribing information for Latisse includes
  warnings related to skin changes such as possible
  lid pigmentation of the periorbital tissue and
  hair growth outside the treatment area. The most
  common adverse events caused by Latisse use are
  described as eye pruritus, conjunctival
  hyperemia, skin hyperpigmentation, ocular
  irritation, dry eye symptoms, and erythema of the
  eyelid. These common adverse events have been
  described in less that 4 of patients.
• Usually occurs at 2-3 months (3-6 months for
  Lumigan)
• May be reversible
• When application frequency was reduced to 2
  nights per week, lash enhancement and skin
  changes remained unchanged.
• Reference Arch Oph, June, 2010

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Trends in Systemic Prescribing

For neuropathic pain (neurotransmitter inhibitors) For neuropathic pain (neurotransmitter inhibitors) For neuropathic pain (neurotransmitter inhibitors)
Neurontin (gabapentin) Lyrica () (pregabalin)

For bladder control (antimuscarinic agents) For bladder control (antimuscarinic agents) For bladder control (antimuscarinic agents)
Detrol (tolterodine) Vesicare (solifenacin) (and many others)

For breast cancer treatments (aromatase inhibitors) For breast cancer treatments (aromatase inhibitors) For breast cancer treatments (aromatase inhibitors)
Tamoxifen (nolvadex) Aromasin (exemestane) (and many others)

Source Pharmacists Letter / Prescribers Letter (April 04, May 07 and January 08.) Source Pharmacists Letter / Prescribers Letter (April 04, May 07 and January 08.) Source Pharmacists Letter / Prescribers Letter (April 04, May 07 and January 08.)
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Ocular Lymphangiectasis

• History patient notices blister on conjunctiva
  may be associated with irritation
• Clear, fluid-filled dilation of conjunctival
  lymphatic vessels
• Single or multiple small, transparent pearl-like
  blebs or cysts
• Surrounding bulbar conjunctiva quiet
• ICD-9 code 372.89
• Treatment
• Patient reassurance
• Drainage of blebs/destruction