case presentation of recurrent peripheral infiltrative keratitis
TRANSCRIPT
Case Presentation of Recurrent Peripheral Infiltrative Keratitis
(PIK) of Unknown Cause
4/17/13 Northeastern State
University
60’s Caucasian male, red eye ODMedical/ocular hx:• No contact lenses, ocular surgeries or trauma• hx of left orbital pseudotumor (neg CT ‘03) • has mild dry eyes and seasonal allergies• no known autoimmune/collagen vascular dis. • hx of insect bite with rash• past blood work unremarkable • closely followed for > 10 yrs; + hypothyroidism• (NOTHING JUMPS OUT)
Some questions we want answered
• Is this red eye infectious?• Is this red eye autoimmune?• Is this red eye blepharitic?
Next slide: BEGINS THE EXAM
OCULAR EXAM FINDINGS INCLUDE:• Visual acuity and posterior
segment are unremarkable• Left eye never became involved
January 2013 Visits for Right eye
1st wk/visit 2nd week 3rd week 4th week
History Red/irritated/burn 1 wk
5/10 tenderness
light sensitive
Less red/irritated/burn
2/10 tenderness
Less light sensitive
Less red/irritated/burn
1-1.5/10 tenderness
Not very light sensitive
Less red/irritated/burn
0/10 tenderness
not light sensitive
Findings + infiltrates ,(+)tr.staining
2-3+ bulbar injection
3+ cells
+ infiltrates , (-) staining
1-2+ bulbar injection
1-1.5+ cells
Less dense infiltrates
mild bulbar injection
no cells
Less dense infiltrates
no injection, (+)pannus
A and P Peripheral Infiltr. Keratitis (PIK)Anterior Uveitis (AU)Pred Forte (PF)
PIK severe epi/mild scleritisAU
PF q1-2hrs/dayCyclo 3xVigamox 4x
PIKsevere epi/mild scleritisAU
PF 5x/dayCyclo 3xVigamox 3x
Resolving PIKmild episcleritisresolved AU
PF 4x/dayStop CycloStop Vigamox
Resolving PIKresolved episcleritis
PF 3x/day for 2wks, then 2x/day til return
RTC 2 days 5 days 1-2 weeks 3 weeks
February/March 2013 Visits for Right eye
Mid February
1st wk of March
3rd wk of March
4th week of March
History 0/10 tenderness
not light sensitive
no scalp/jaw pain
0/10 tenderness no complaintsPt did not stop taking PF
0/10 tenderness no complaintsStopped PF as directed
0/10 tenderness not light sensitive mild scalp pain
Findings IOP 33 (-) infiltrates (+) lipid deposits Gonio stable/open
IOP 32 no change
IOP normal 3 brightly staining infiltrates, no ulcer1+ cell
IOP normal 3 minimally staining infiltrates no cells
A and P Peripheral Infiltrative Keratitis (PIK)Anterior Uveitis (AU)Pred Forte (PF)
Resolved PIKOHTN vs steroid response (hx of 31 untreated pressure)Taper PF for 1 wk then stop PF
Same
Stop PF immediately
Recurring PIK AU
PF q2-3hrCyclo 2x
Recurring PIK, resolved AUPF q2-3hrCyclo 2xAdditional Labs in case of worsening/ reoccurrence
RTC 2 weeks 2 weeks 5days 2 weeks
BEGIN DIFFERENTIALS1. Infectious Keratitis
OCULAR, LOCAL, MOST SEVERE DISEASE
2. Systemic causes (includes infection)3. Blepharitis associated disease
OCULAR, LOCAL, LESS SEVERE NON INFECTIOUS DISEASE
OCULAR, LOCAL,MOST SEVERE DISEASEBACTERIAL OR FUNGAL KERATITIS
ABSENT PRESENTdischarge
decreased vision
epithelial defect
hypopyon
worse w/ steroid alone
Kanski: Characteristics of INFECTIVE vs STERILE corneal infiltratesSize Tend to be larger Tend to be smallerProgression Rapid slowEpithelial defect Very common and
larger when presentMuch less common and if present tend to be small
Pain Moderate to severe mildDischarge Purulent mucopurulentSingle or multiple Typically single Commonly multipleUnilateral or bilateral Unilateral Often bilateralAC Rxn Severe mild
Location Often central Typically peripheral
Adjacent corneal rxn Extensive limited
Features
HSV marginal ulcer
Staph. marginal infiltrate
Etiology Active HSV Immunologic response to staph. antigen
Epithelial defect Always
Absent (if present, late)
Neovasc. Often Never Progression
Centrally Circumferentially
Blepharitis
Unrelated Usually
Location Any meridian Typically 2, 4, 8, 10 o’clock meridians
Skin +/- vesicles blepharitis
OCULAR, LOCAL,MOST SEVERE DISEASE
HSV stromal keratitisSeen here but absent in our pt:-INFILTRATE SPREAD CENTRALLY-stromal neovasc. Present (THIS IS IMAGE IS ONE EXAMPLE OF INTERSTITIAL KERATITIS)
-not ruled out yet
SYSTEMIC (DISTANT CHANGES) 1. Interstitial Keratitis (IK)
-Hallmark are ghost vessels2. Peripheral Ulcerative Keratitis (PUK)
-EPITHELIAL DEFECT
DUANE’s ONLINE Systemic Disease
Corneal Change
Patho-gnomonic
Suggestive(distant
disease)
Nonspecific(local disease)
Infiltrates NONE Crohn's disease
(peripheral infiltrate)Acne rosacea and other skin diseases
(FORCEDTOINVEST-IGATE)
Leukemia (marginal infiltrates and deposits)
Blepharitis associated marginal keratitis
(ADDRESS LATER)
Interstitial
Keratitis
NONE Syphilis
MANY OTHERS(ADDRESS NEXT)
Hallmark of Interstitial Keratitis Stromal Ghost vessels/neo
Interstitial KeratitisBacterial infection Parasitic infectionSyphilis (could be latent) No skin changes, noTuberculosis (neg Tb tests) diarrhea, and no contactLeprosy (skin) lens wearLyme disease (+ hx insect bite with rash)Brucellosis (no fever) Trachoma (no conj scar)Viral infection Systemic diseaseHerpes simplex virus Cogan's syndr.(hearing okay)Herpes zoster virus (skin) Sarcoidosis (neg. chest XR)Epstein-Barr virus (no symp) Lymphoma (no symptoms)Mumps (no symptoms) Measles (skin)HTLV-1 (no demyelinating)
Kanski: Peripheral Ulcerative Keratitis
THINNED CONSIDERABLY
Peripheral Ulcerative Keratitis
ONLY SHOWING DIFFERENTIALS NOT ALREADY DISCUSSED
Parasitic infection
OcularSuperior limbic keratoconj.Systemic
Rheumatoid arthritis (negative)
Bacterial infection Wegener’s Gran. (neg ANCA)Syphilis (could be latent) Lupus (neg ANA 2002)Viral infection Malignancy (hx of bladder)Herpes simplex virus Lupus (neg ANA 2002)Hepatitis C (negative 1999)
Inflam. bowel dis (negative colonoscopy)
AIDS (normal WBC 2013) Others (including Sjogren’s)
I. Blepharitis Assoc. Keratitisincludes:
1. Marginal keratitis2. Phlyctenulosis3. Ocular Rosacea
LOCAL CAUSES
I. Blepharitis Associated KeratitisABSENT PRESENT
Less than 2 clock hours of the peripheral cornea
Less ulcerative tendency
Does not progress centrally
LOCAL CAUSES
Signs of blepharitisABSENT MILDLY PRESENT
crustiness, collarettes, flaking
telangiectasia of eyelids and face
chronic papillary conjunctivitis
meibomian gland dysfunction
LOCAL CAUSES
Marginal keratitis ABSENT PRESENT
surrounded by 1mm clear zone
Anterior stromal infiltrate
Usually less than 1 clock hour long
Predilection for 2, 4, 8, 10 o’clock positions
In some cases multiple infiltrates can coalesce to form a larger ring infiltrate
LOCAL CAUSES
Kanski: Marginal Keratitis
Phlyctenulosis ABSENT PRESENT
pinkish white nodule usually originating at limbus
as lesion evolves the elevated nodule ulcerates
recurrent lesions extend farther toward central cornea
LOCAL CAUSES
LOCAL CAUSES
Ocular RosaceaABSENT PRESENTsome infiltrates ulcerate and can perforate
cutaneous signs need not be severe for ocular involvement
diffuse gray opacification of peripheral stroma with superficial vascularization
Severe cases develop recurrent peripheral infiltrates central to peripheral vascularization
Kanski: Ocular Rosacea
Severe cases develop recurrent peripheral infiltrates central to
peripheral vascularization
Kanski: Summary of characteristics of chronic blepharitisAnterior blepharitis Posterior
bleph.Feature Staphylococcal Seborreic
Lashes Deposit Hard SoftLoss ++ +Distorted/trichiasis ++ +
Lid Margin Ulcer +Notch + ++
Cyst Hordeolum ++Meibomian ++
Conjunctiva Phlyctenule +Tear Film Foaming ++
Dry eye + + ++
Cornea(phlyctenules not included)
Punctuate erosions + + ++Vascularization + + ++infiltrates + + ++
Assoc. Disease Atopic disease Seb. dermatitis Acne RosaceaMarginal Keratitis clear zone
Some questions we want answered
• Is this red eye infectious?• Is this red eye autoimmune?• Is this red eye blepharitic?•None have been answered completely but we have identified the next steps
To address infection & autoimmunity:
• herpes antibody titers• Lyme titer• FT-ABS, VDRL• Culture the infiltrate• antithyroid peroxidase antibodies• Anti SSA and anti SSB• Rheumatologic consultation
To address blepharitic causes:
•Antibiotic ointment•Educate pt to greater attention to lid hygiene
•Responsiveness to doxycycline