marginal ulcers or peripheral ulcerative keratitis · 2020-04-20 · • in this interactive...

Guillermo Rocha

W Bruce Jackson

Marginal Ulcers orPeripheral Ulcerative Keratitis

• In this interactive module, peripheral ulcerative keratitis will be reviewed. This will be in the context of a diagnostic classification, management algorithm and case presentations.

Learning Objectives

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To better understand the various etiologies of corneal ulcers including Infectious vs. Non-Infectious and Systemic vs Local

Discuss the approach to diagnosis including dry eye testing, review of systems, cultures and systemic testing

Review management principles including wound healing, prevention of perforation and addressing the underlying condition

• Crescent shaped, destructive inflammatory lesion affecting the juxtalimbal corneal tissue

• Often associated with systemic disease

• May signify “vasculitis” and thus, be potentiallylife-threatening

Peripheral Ulcerative Keratitis (PUK)

3Rowe JA, Barney NP. Principles and Practice of Cornea, Ch 32; Copeland, Afshari, Eds.

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These are all PUK –How do you manage them?

MARGINAL INFILTRATIVE / ULCERATIVE KERATITIS

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Bacteria and Fungi Viruses Acanthamoeba

Systemic Autoimmune/Inflammatory

Local Toxic

InfectiousSterile

Etiology

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1 2

3 4

5 6

What would you use?

• No therapy• Antibiotics• Steroids• Antifungals• Antihistamines• Systemic drugs

TWO CASES TO CONSIDER

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8

What would you do?

• History

• The patient

• Previous therapies

KNOW MORE ABOUT…

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What would you do?

• Enhance wound healing

• Prevent perforation

• Address the underlying condition

MANAGEMENT PRINCIPLES

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ETIOLOGIC CONSIDERATIONS

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LOCALNON-INFECTIOUS

SYSTEMIC NON-INFECTIOUS

LOCALINFECTIOUS

SYSTEMIC INFECTIOUS

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Which is which?

LOCALNON-INFECTIOUS

LOCAL INFECTIOUS

SYSTEMIC NON-INFECTIOUS

LOCAL INFECTIOUS

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Which is which?

NON INFECTIOUS PERIPHERAL INFILTRATIVE KERATITIS

15Stern GA. Cornea, Ch 23; Krachmer, Mannis, Holland, Eds.

Microulcerative

Macroulcerative

• Generally manifestation of systemic, immune-mediated disease

• Most common: Rheumatoid arthritis, Wegener’s granulomatosis and polyarteritis nodosa

NON INFECTIOUS PERIPHERAL INFILTRATIVE KERATITIS

Stern GA. Cornea, Ch 23; Krachmer, Mannis, Holland, Eds. 16

Microulcerative

Macroulcerative

• Punctate marginal keratitis

• Peripheral keratitis associated with blepharitis

NON INFECTIOUS PERIPHERAL INFILTRATIVE KERATITIS

17Stern GA. Cornea, Ch 23; Krachmer, Mannis, Holland, Eds.

Microulcerative

• Punctate marginal keratitis

– Staphylococci, Streptococci, Haemophilus, hypersensitivity to medications

• Peripheral keratitis associated with blepharitis

– Catarrhal ulceration

– Phlyctenulosis

– Peripheral rosacea keratitis

• Size

• Number

• Location

• Intervening space

• …not really, although:

– Catarrhal may have intervening space, and be located at the 2, 4, 8 and 10 o’clock positions

Are There Any Distinguishing Features?

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PERIPHERAL CORNEAL INFLAMMATION

Stern GA. Cornea, Ch 23; Krachmer, Mannis, Holland, Eds. 19

INFECTIOUS IMMUNOLOGIC

EPITHELIUM Usually epithelial defect Usually intact initially

DISCHARGE Usually Unlikely

INFILTRATES Spread centrally Spread concentrically

HYPOPYON Common Uncommon

• Treat without testing?

• Treat, but testing required?

Which Ones Need to Be Worked Up?

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LOCALNON-INFECTIOUS

SYSTEMIC NON-INFECTIOUS

LOCALINFECTIOUS

SYSTEMIC INFECTIOUS

• Avoid treating with topical steroids

HERPETIC ULCERS (HSV)

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CONSIDER THE ROLE OF:

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DRY EYETESTING

REVIEW OF SYSTEMS

CULTURES SYSTEMICTESTING

• Dry Eye Questionnaire

• Assessment of lid margins

• Tear film breakup time

• Corneal and conjunctival staining

• Tear osmolarity

• Schirmer test

• Serology: SSA, SSB, Rheumatoid Factor, ANA

DRY EYE TESTING

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BACK TOSLIDE 78

BACK TOSLIDE 97

• Bacterial

• Viral

• Fungal

• Acanthamoeba

• Chalmydia

CULTURES

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BACK TOSLIDE 78

BACK TOSLIDE 97

• Rule out those conditions associated with peripheral ulcerative keratitis

REVIEW OF SYSTEMS

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BACK TOSLIDE 78

BACK TOSLIDE 97

• Complete blood count

• Erythrocyte sedimentation rate

• C reactive protein

• Urinalysis

• Chest X-ray

• Renal function tests

• Syphilis, Hepatitis C

SYSTEMIC TESTING

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BACK TOSLIDE 78

BACK TOSLIDE 97

• Rheumatoid factor

• Antinuclear antibodies

• Antineutrophil cytoplasmic antibodies (ANCA)

• Tissue biopsy

– Lung, kidney

SYSTEMIC TESTING

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BACK TOSLIDE 78

BACK TOSLIDE 97

MARGINAL INFILTRATE

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When to culture?

When to use antibiotics?

When to add steroids?

ETIOLOGIC CONSIDERATIONS

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LOCALNON-INFECTIOUS

ETIOLOGIC CONSIDERATIONS

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• Catarrhal infiltrates• Phlyctenulosis• Acne rosacea• Psoriasis• Contact lenses• Topical anesthetic abuse• Toxic• Food allergies• Mooren’s ulcer (??)

LOCALNON-INFECTIOUS

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ETIOLOGIC CONSIDERATIONS

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LOCALINFECTIOUS

ETIOLOGIC CONSIDERATIONS

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• Bacterial• Viral• Fungal• Acanthamoeba

LOCALINFECTIOUS

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• One infiltrate

• Larger than 2mm in diameter

• Less than 3mm from the visual axis

ALWAYS CULTURE

1-2-3 RULE

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• History of contact lens wear or trauma

• Non resolving

• Ring infiltrate

ALWAYS CULTURE

CONSIDER CORNEAL BIOPSY

ALSO…

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ETIOLOGIC CONSIDERATIONS

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SYSTEMIC INFECTIOUS

ETIOLOGIC CONSIDERATIONS

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• Herpes virus• ChlamydiaSYSTEMIC

INFECTIOUS

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ETIOLOGIC CONSIDERATIONS

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SYSTEMIC NON-INFECTIOUS

ETIOLOGIC CONSIDERATIONS

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• Rheumatoid arthritis• SLE• Discoid lupus• Scleroderma• Relapsing polychondritis• Crohn’s• Ulcerative colitis• Polyarteritis nodosa• Wegener’s granulomatosis• Churg-Strauss• Benign hypergammaglobulinemic

purpura• Temporal arteritis

SYSTEMIC NON-INFECTIOUS

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• Enhance wound healing

• Prevent perforation

• Address the underlying condition

MANAGEMENT PRINCIPLES

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ENHANCE WOUND HEALING

• Lid Hygiene

• Antibiotic coverage

• Lubrication: Preservative-free

• Autologous serum drops

ENHANCE WOUND HEALING

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64

PREVENT PERFORATION

• Collagenase or collagenase synthetase inhibitors

– 1% Medroxyprogesterone

– 10-20% Acetylcysteine

• Cyclosporine 0.05%

• Doxycycline

• Tissue adhesive, bandage CL, lamellar and tectonic grafts, amniotic membrane transplant

• CAUTION: topical steroids

PREVENT PERFORATION

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ADDRESS THE UNDERLYING CONDITION

• Glucocorticoids

– IV pulse initially

– Oral

• Systemic immunomodulators

– Antimetabolites

– Alkylating agents

– T cell inhibitors

– Biologics

ADDRESS THE UNDERLYING CONDITION

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• Glucocorticoids

– IV pulse initially: 1g per day, for 3 consecutive days

– Oral: 1mg/kg/day, not to exceed 60-80 mg/day

ADDRESS THE UNDERLYING CONDITION

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• Systemic immunomodulators

– Antimetabolites:

• MTX, AZT, Mycophenolate mofetil, Leflunomide

– Alkylating agents:

• Cyclophosphamide

– T cell inhibitors:

• Cyclosporin A

– Biologics:

• Infliximab, etanercept, rituximab

ADDRESS THE UNDERLYING CONDITION

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Back to Our Two Cases to Consider

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What would you do?

• History

• The patient

• Previous therapies

KNOW MORE ABOUT…

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• 62yoM

• Original presentation: conj cyst OD -marsupialization

• MGD = full Lid Hygiene, tea tree oil facewash, Doxycycline

• Possible history of CRVO? Amblyopia?

• 5 mo later: PUK

CASE HISTORY SH

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CASE HISTORY SH

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CASE HISTORY SH

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CASE HISTORY SH

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CASE HISTORY SH

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What would you do?

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• Do you think this is Dry Eye/Ocular Surface related?

• Do you think this is a local infection?

• Do you think this is related to a systemic condition?

• Do you think systemic testing is warranted?

• 62yoM

• Original presentation: conj cyst OD -marsupialization

• MGD = full Lid Hyg, TTO, Doxy

• Possible history of CRVO? Amblyopia?

• 5 mo later: PUK

• Prednisolone acetate 1% tid –better 3 wks later

• Tests: all negative, except atypical ANCA

CASE HISTORY SH

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CASE HISTORY SH: 3 WEEKS LATER

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• Worse again: 20/60

• New lesions superiorly and inferiorly

• What would you do?

ONE MONTH LATER…

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• Enhance wound healing– Lid hygiene

– Fucidic acid to lids

• Prevent perforation– Prednisolone acetate 1%

– Doxycycline 100mg PO qhs

• Address the underlying condition– Systemic testing: Atypical ANCA (+)

– Referral to Internal Medicine

MANAGEMENT HISTORY

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IMPROVED AND STABLE

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IMPROVED AND STABLE

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WHAT ABOUT ANCA?

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• Antineutrophil cytoplasmic antibodies are specific and sensitive markers for different forms of vasculitides

ANCA

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• 51yoF

• Glaucoma on multiple meds

• Chronic red eye OS 1-2 yrs

• Is this toxic? Stopped everything

• Some improvement, but…

• 4-5mo later, worse, gooey, leaky, on Pataday

• Now with PUK

• OD perfectly fine

CASE HISTORY FW

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CASE HISTORY FW: 5MO

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CASE HISTORY FW: 5MO

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CASE HISTORY FW: 5MO

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CASE HISTORY FW: 5MO

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CASE HISTORY FW: 5MO

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CASE HISTORY FW: 8MO

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CASE HISTORY FW: 8MO

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CASE HISTORY FW: 8MO

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What would you do?

97

• Do you think this is Dry Eye/Ocular Surface related?

• Do you think this is a local infection?

• Do you think this is related to a systemic condition?

• Do you think systemic testing is warranted?

• 51yoF

• Glaucoma on multiple meds

• Chronic red eye OS 1-2 yrs

• Toxic? Stopped everything

• 4-5mo later, worse, gooey, leaky, on Pataday

• PUK

• Cultures:

– Dx Strep Anginosus, Eikenella corrodens

– Sensitive to Ciprofloxacin –Improved!

CASE HISTORY FW

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CASE HISTORY FW:Follow Up –on Ciprofloxacin gtt/ung

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CASE HISTORY FW:Follow Up –on Ciprofloxacin gtt/ung

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CASE HISTORY FW:Follow Up –on Ciprofloxacin gtt/ung

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CASE HISTORY FW:Follow Up –on Ciprofloxacin gtt/ung

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• Worse again!

• Marked inflammation, PUK, discharge, corneal thinning and vascularization

• Extreme photophobia

• NO intraocular inflammation

BUT… 2 MO LATER

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What would you do?

• Enhance wound healing– Lid hygiene

– Continue with topical ciprofloxacin

• Prevent perforation– IV Methylpredisolone 1g daily for 3 days

– Continue with oral Prednisone

• Address the underlying condition– Referral to Internal Medicine: IMT

• Improved at last visit

MANAGEMENT HISTORY

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LATEST FOLLOW-UP

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LATEST FOLLOW-UP

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• Well controlled on oral Prednisone and Methotrexate

ETIOLOGIC CONSIDERATIONS

DIAGNOSTIC CONSIDERATIONS

MANAGEMENT PRINCIPLES

SUMMARY

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ETIOLOGIC CONSIDERATIONS

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LOCAL NON-INFECTIOUS

SYSTEMIC NON-INFECTIOUS

LOCALINFECTIOUS

SYSTEMIC INFECTIOUS

DIAGNOSTIC CONSIDERATIONS:

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DRY EYETESTING

REVIEW OF SYSTEMS

CULTURES SYSTEMICTESTING

MANAGEMENT PRINCIPLES:

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ENHANCEWOUND HEALING

PREVENT PERFORATION

ADDRESS UNDERLYING CONDITION

REFERAS NEEDED