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TMOD Flashcards

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1
Q

Goals of treatment: Aqueous Deficient Dry Eye

A

replace lost tears through supplementation, stimulation or medication, conserve present tears, control secondary inflammation

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2
Q

Which medications control secondary inflammation in ADDE?

aqueous deficient dry eye

A

Cyclosporine 0.05% (Restasis) 2x/ day
Fluoromethalone 0.1% suspension QID x 2-3 weeks or loteprednol 0.2% or 0.5%

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3
Q

What treatment conserves present tears?

A

punctal occlusion

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4
Q

Treatment options for severe dry eye

A

filaments: acetylcysteine 10% QID
GP or scleral CL; autologous serum, amniotic membrane

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5
Q

Follow up for Aqueous Deficient Dry Eye

A

Mild: 3-6 months; Moderate-Severe: 4-8 weeks

cyclosporine takes 6-8 weeks for benefits; Xiidra takes several months for maximal treatment

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6
Q

Evaporative Dry eye is a deficiency in which layer of the tears?

Evaporative is the predominant type of dry eye

A

outer lipid layer

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7
Q

What are the goals of treatment for evaporative dry eye?

A

stablize the tear film

warm compress, lid hygiene, medication (neutraceuticals)

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8
Q

Treatment options for moderate evaporative dry eye

A

1) Topical antibiotic ointment QPM (erythromycin, bactracin, ofloxacin)
2) in office blephex/ zest; debridement; lipiflow; IPL
3) Oral Ab: doxycyline 50 mg QD x 2-4 months

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9
Q

Treatment options for severe evaporative dry eye

A

1) gland probing
2) Surgery for lid abnormalities (ectroption, entropion, proptosis, lagophthalmos)

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10
Q

Conservative treatment regimen for allergic conjunctivitis

A

1) cool compress
2) artificial tears
3) topical vasoconstrictors and antihistamines

Emadine (emadastine difumerate 0.05%) QID; Bepreve (bepodastine besilate 1.5%) BID

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11
Q

Treatment for chronic allergies

A

oral antihistamines with PFAT; topical mast cell stabilizers; combo mast cell/ antihistamine takes affect faster

mast cell only: Alomide (QID), alomast (QID), alocril (BID); crolom (QID)
combo: pataday, optivar (BID); elestat (BID)

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12
Q

First and second line for treatment of local inflammation related to allergic conjunctivitis

A

First line: Steroids: loteprednol etabonate 0.2% QID; Flarex 4-6x/ day; Lotemax QID; Pred Forte as often as q1-2h x 7 days, then taper
Second line: restasis: long term management

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13
Q

Follow up for Allergic Conjunctivitis

A

2 weeks

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14
Q

Goals of treatment for viral conjunctivitis

A

prevention of spreading; palliative care; quiet initial inflammatory response

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15
Q

When should steroids be used in viral conjunctivitis

A

In the presence of membranes and/ or persistant subepithelial infiltrates

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16
Q

Which steroids are used in viral conjunctivitis

A

FML forte, flarex; lotemax

rapid taper

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17
Q

What are palliative measures for viral conjunctivitis

A

cool compress, artificial tears, lid hygiene

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18
Q

What is the role of topical antibiotics like erythromycin ointment in viral conjunctivitis

A

prevent secondary bacterial infection

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19
Q

What can be used EARLY in EKC infection?

controversial

A

Betadine wash

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20
Q

How long is EKC considered infectious?

A

2 weeks

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21
Q

What is the timeline for non-specific adenoviral conjunctivitis to resolve?

A

2-3 weeks

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22
Q

What signifies an immune repsone in EKC and signals that the patient is no longer contagious?

A

SEI’s

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23
Q

What can we use if a patient is experiencing itching along with viral conjunctivitis?

A

topical antihistamine

epinastine 0.05% BID

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24
Q

What is the follow up for viral conjunctivitis with and without steroids?

A

(-) steroids: 2-3 weeks or sooner if worsening
(+) steroids: 1 week

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25
What is the role of any topical treatment given in gonococcal conjunctivitis?
adjunctive; includes warm saline rinse QID; erythromycin, tobramycin or bacitracin ung QID; topical fluoroquinolones q2h x 4-7 days: cipro, levo, oflox, moxi or gatifloxacin)
26
What is the systemic treatment for gonococcal conjunctivitis without keratitis?
Ceftriaxone 1g IM/ IV in a single dose
27
What is the systemic treatment for gonococcal conjunctivitis with keratitis?
Hospitalize; Ceftriaxone 1g IV q12-24h x 3 days or until symptoms subside
28
What is the follow up for gonococcal conjunctivitis?
Daily until improvement, then every 2-3 days until resolution
29
What is the treatment for Chlamydia?
Azithromycin 1g po single dose or Doxycycline 100 mg BID x 2 weeks ## Footnote Adult inclusion: serotype D-K; Trachoma: serotype A-C
30
Treatment for mild blepharitis
Lid hygiene BID, warm compress BID-QID; PFAT q4-6h
31
Treatment for moderate blepharitis
all mild treatments plus erythromycin ointment or azithromycin gel to eyelids QHS; cyclosporine 0.05% or 0.09% BID; lifitegrast 5% BID ## Footnote cyclosporine= cequa/ restasis; lifitegrast = Xiidra
32
Which type of neutraceutical is best for blepharitis and MGD?
Omega-3
33
Unresponsive MGD treatment
topical Ab/Steroid combo: tobramycin 0.3%-dexamethasone 0.1% or tobramycin 0.3%/ dexamathasone 0.05% BID-TID); consider oral doxycycline 50- 100 mg po BID for 3-4 weeks Tetracycline 250 mg QID po x 3-4 weeks ## Footnote lower doxy to once a day over a period of months, can use maintanence dose of 1/4th orginal for 3-6 months
34
In office procedures for resistant blepharitis/ meibomitis?
IPL, Lipiflow, gland expression; blephEx/ Zest; gland probing
35
What is the role of oral tetracyclines in MGD?
reduce inflammation, decrease the conversion of glandular lipids to free fatty acids
36
What is the treatment for CLARE?
Discontinue contact lens wear; begin prophylactic Ab/steroid combo (tobradex QID x 7 days) ## Footnote CLARE should improve over 1-3 days
37
What is the follow up for CLARE?
daily until improvement
38
What contact lens associated condition has small infiltrates in the anterior stroma and does NOT have an epi defect?
CLAIK | aka "tight lens syndrome"
39
What is the treatment for CLAIK?
d/c CL wear, solution change, lens material change; ophthalmic steroids prn- condition may self resolve in 2 weeks; artificial tears ## Footnote can Rx tobradex QID; if (+) AC cells or photophobic: can Rx cycloplegic
40
41
Which type of contact lenses are most associated with CLPU? ## Footnote contact lens peripheral ulcer
extended wear CL and silicone hydrogel
42
What is the treatment for CLPU?
moxifloxacin 0.5%: loading dose q30m x 6 hrs; q1h x 18 hours ## Footnote escalate to fortified vancomycin if ulcer enlarges, becomes visually significant or if there is deep stromal involvement, a hypopyon or corneal thinning
43
What is the follow up for CLPU?
daily until improvement
44
Which type of antibiotic is best for bacterial keratitis | including pseudomonas
fluoroquinolone; if sight threatening: besifloxacin; if wanting least cyctotoxic: levofloxacin ## Footnote don't forget the loading dose!
45
What is an alternative to Besivance if dealing with a sight threatening bacterial keratitis?
fortified vancomycin alternating with ceftiazdime
46
What is the next step when a patient is non-compliant with a sight threatening bacterial keratitis?
hospitalization: IV vanco
47
What is the treatment for a corneal abrasion in a non-contact lens wearer?
Topical antibiotic: polymixinB/ trimethoprim soln QID w/ tobramycin ointment at night ## Footnote if fingernail or vegetative trauma: cover with fluoroquinolone QID
48
What is the treatment for a contact lens wearer with a corneal abrasion?
Topical fluoroquinolone (pseudomonas coverage) or tobrabymin gtts QID with ciprofloxacin or tobramycin ung QPM ## Footnote think besifloxacin, moxifloxacin, gatifloxacin, ofloxacin or ciprofloxacin
49
When is a BCL used in corneal abrasion treatment?
large abrasions
50
When is cyclopentolate used in corneal abrasion treatment?
when there is traumatic iritis ## Footnote cyclopentolate 1% BID-TID
51
What is a treatment option if the corneal abrasion is painful?
ketorolac 0.4% QID x 3 days
52
What is the typical follow up for a corneal abrasion? | think small and/ or peripheral
2-5 days, then 3-5 days; follow until re-epithelialization
53
What is the follow up for a large or centrally located abrasion or any abrasion when a BCL was placed?
1 day ## Footnote follow until re-epithelialization
54
What is the initial treatment for an RCE?
1) cyclopentolate 1% QID or atropine 1% QD 2) PolymixinB/ trimethoprim QID 3) PFAT
55
What is the treatment for RCE after repithelialization occurs?
1) Muro 5% ung QPM 4-6 weeks 2) PFAT- tons ## Footnote *if failure to repithelialize: BCL w/ oral doxy 50 mg BID and FML/lotepred 3x/ day x 4 weeks
56
When would PTK or superficial keratectomy be used as treatment for RCE?
In the case of large RCE or RCE in optic axis ## Footnote stromal micropuncture therapy can be used for large RCE outside visual axis
57
What is the goal of scleritis treatment?
stop/ avoid scleral destruction
58
What is the treatment for non-necrotizing manifestations of scleritis?
Oral NSAIDs: may need to try more than one before moving to oral steroids ## Footnote if oral meds are contraindicated, can use triamcinolone injection over the nodule (not as effective)
59
Treatment for diffuse and nodular scleritis
1) Oral NSAID: flurbiprofen 100 mg (if fail- naproxen 250-500 mg po BID or indomathacin 25-50 mg po TID) *if fail, then* 2) Oral Steroid: 60-80 mg QDx 1 week, taper to 20 mg QD x 2-6 weeks with slow taper (oral NSAID can help taper) *if more aggressive tx needed, then* 3)methyl-prednisolone succinate injection 1000 mg x 3 days followed by oral *Long term steroid use: vitamin d supplementation to prevent osteoporosis*
60
Follow up for diffuse and nodular scleritis?
3 days | can vary by severity
61
Treatment for necrotizing scleritis?
**more severe = more aggressive** 1) Oral steroid: 1mg/kg/ day, taper over weeks 2)Immunosuppressive, monitor risk of scleral perforation | immunosuppressive = Rituximab, methotrexate ## Footnote coordinate with rheumatology, internal medicine or uveitis specialist
62
What is the treatment for infectious scleritis?
*must debride- early is best, culture and stain* 1) topical and systemic fluoroquinolone for broad spectrum treatment; use culture results to guide treatment ## Footnote follow up is daily until clinical improvement is noted
63
Treatment for mild episcleritis?
PFAT at least QID
64
Follow up for mild episcleritis
1 month if only AT's used, sooner if signs/symptoms worsen
65
Treatment for moderate- severe episcleritis
1) Topical NSAID: diclofenac 0.1% QID OR 2) mild steroid: fluoromethalone 0.1% or 0.25% QID OR loteprednol 0.5% QID 3) *if needed: oral NSAID: ibuprofen 200 mg TID* ## Footnote generally self-limiting: can resolve in 1-3 weeks
66
follow up for moderate-severe episcleritis
every 2 weeks until symptoms resolve, then taper steroid administration
67
Treatment for VKC/AKC?
1)Palliative: cool compress and PFAT QID 2) prophylactic mast-cell stabilizer or combo anti-histamine/mast-cell stabilizer 3) *if (+) shield ulcer*: topical steroid: loteprednol 0.5% or pred acetate 1% QID with antibiotic drop: trimethoprim/polymixin B QID or ointment: erythromycin or trimethoprim/polymixin B QID 4) *if (+) filaments or excessive mucous:* acetylcysteine 10% QID **if unresponsive:** cyclosporin 0.5-2.0% BID-QID; mitomycin C 0.01% TID x 2 weeks 5) *if (+) atopic dermatitis*: tacrolimus 0.03-0.1% qhs-BID; fluorometholone 0.1% qid x 1-2 weeks
68
Follow up for VKC/AKC?
*(-)shield ulcer: *3 weeks *(+) shield ulcer:* **daily** | monitor IOP while on steroids
69
What is the treatment for preseptal cellulutis?
1) warm compress TID, nasal decongestant 2) systemic antibiotic:Adults: 500 mg augmentin BID x 10 days Children: 25-40mg/kg/day in 2 divided doses 3) *if (+) conjunctivitis*: polymixin B/bacitracin ung QID 4) *if (+) inflammation: systemic steroids*: can start during or after (24-48 hrs) after antibiotic depending on significance of inflammation 5) Nasal decongestant 6) Debridement and culture if mass/ abcess present **if failure of oral antibiotics, admit to hospital, consult infectious disease: IV treatment and orbital CT scan needed** | Keflex 500 mg QID is another choice ## Footnote if allergic to penicillin: doxycycline 100 mg BID x 7 days; bactrim 800 mg BID; clindamycin or Z-pack
70
What is the follow up for preseptal cellulitis?
daily until improvement noted; then every 3 days until resolution
71
Treatment and follow up for filamentary keratitis?
1) In office debridement (proparacaine on cta) 2) PFAT QID 3) +/- punctal occlusion (if severe dry eye) 4) acetylcysteine 10% QID Follow Up: 2 weeks; if tx failure BCL with topical Ab
72
What two conditions are associated with phyctenulosis?
blepharitis, TB
73
Treatment for phylectenulosis?
* *(+) blepharitis*: lid hygiene, antibiotic oitment BID * Topical steroid: pred acetate 1% QID x 7 days *or* * Combination drop: tobradex qid x 7 days; Zylet qid x 7 days
74
follow up for phylectenulosis?
5 days ## Footnote recovery is expected over 10-14 days; expect faint stromal scar; start taper of steroid once symptoms improve
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