Eyeworld

43 EW FEATURE May 2018 • Navigating the red eye HZO related to shingles would be harder to miss, Dr. Mah said, due to the patient likely having a history of a rash or still presenting with a rash. "It's harder to miss, but you don't want to miss either of these because both can cause permanent vision issues," Dr. Mah said. Blepharitis and allergic con- junctivitis could be confused with a bacterial or viral infection as well, Dr. Mah added. Dr. Verdier also listed several conditions that shouldn't be con- fused as bacterial or viral conjunc- tivitis including fungal infections, Acanthamoeba, microsporidia, and neoplasia (including squamous cell or sebaceous carcinoma). EW References 1. Shekhawat NS, et al. Antibiotic prescription fills for acute conjunctivitis among enrollees in a large United States managed care net- work. Ophthalmology. 2017;124:1099–1107. 2. Sheikh A, et al. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2006:CD001211. 3. Yabiku ST, et al. Ganciclovir 0.15% ophthalmic gel in the treatment of adenovi- rus keratoconjunctivitis. Arq Bras Oftalmol. 2011;74:417–21. 4. Pelletier JS, et al. A combination povidone- iodine 0.4%/dexamethasone 0.1% ophthalmic suspension in the treatment of adenoviral conjunctivitis. Adv Ther. 2009;26:776–83. 5. Warren D, et al. A large outbreak of epidemic keratoconjunctivitis: problems in controlling nosocomial spread. J Infect Dis. 1989;160:938–43. Editors' note: Dr. Mah has financial interests with Shire, Okogen (San Di- ego), IVIEW Therapeutics (Doylestown, Pennsylvania), Bausch + Lomb, and Allergan. Dr. Starr has financial in- terests with Allergan, Shire, Bausch + Lomb, Alcon (Fort Worth, Texas), and Rapid Pathogen Screening (Sarasota, Florida). Dr. Verdier has no financial interests related to his comments. Contact information Mah: mah.francis@scrippshealth.org Starr: cestarr@med.cornell.edu Verdier: daverdier@aol.com Preventing spread in the office Given the highly infectious nature of these conditions, hygiene and disinfection at the clinic is just as important as actions taken at home to prevent nosocomial spread. "In our clinic we treat anyone who is suspicious for an infection in the same way," Dr. Mah said. "The rooms get shut down. You can't put another patient in that room until it has been cleaned. We clean them with disinfecting wipes and clean anything that the patient could have touched in the room." If there are epidemics of ade- novirus EKC, Dr. Mah said patients coming in with red eye won't even stop in the waiting room but will be transferred straight to a "red eye room," which allows staff to isolate infectious agents. This practice has been shown to be effective. For example, in 1985 a quarter of the patients with EKC seen at the Illinois Eye and Ear Infirmary within a 6-month timeframe had acquired the infection at a clinic. 5 Accord- ing to a retrospective report about the epidemic, initial strategies to prevent nosocomial spread were not successful. After the clinic initiated a triage effort where rooms and staff were designated only to infectious patients, nosocomial transmission stopped. Not to be confused with … There are a few other conditions that should not be confused for a case of viral or bacterial conjunctivi- tis. In terms of severity and the po- tential for vision loss, these include HSV and herpes zoster ophthalmic- us (HZO). HSV, Dr. Mah said, is usually monocular and presents with an ul- cerative blepharitis, which can help differentiate it from conjunctivitis. "The eyes might be red, eyelids red and swollen, but if you have an ulcerative blepharitis, if it's been treated for awhile and it's not get- ting any better, you might want to think of HSV. You don't necessarily have to have the corneal findings," he said. Patients with membranes often have severe inflammation, for which Dr. Mah will prescribe ste- roids, along with a recommendation for off-label use of ganciclovir gel. Ganciclovir is approved by the U.S. Food and Drug Administration for HSV keratitis, but there have been studies that show its efficacy against adenoviral conjunctivitis. 3 Overall, Dr. Mah said the course for infectious EKC is about 7–10 days; after that timeframe is when SEIs might appear. SEIs, which can cause a foreign body sensation and blurred vision, are the result of the body's cells getting rid of dead virus particles, Dr. Mah said. He said the normal course of treatment is observation, but if the SEIs are vi- sually significant, steroid drops like loteprednol can be effective. "The tough part is tapering off the steroids; you have to do a slow taper, otherwise the SEIs come right back," he said. Dr. Starr said he will remove membranes if they are causing a foreign body sensation or corne- al staining. Doing this, however, often strips goblet cells and leads to post-viral ocular surface disease, which Dr. Starr said leads him to start patients on topical anti-in- flammatory medications, such as Lotemax (loteprednol, Bausch + Lomb, Bridgewater, New Jersey) in the short term and Restasis (cyclo- sporine, Allergan, Dublin, Ireland) or Xiidra (lifitegrast, Shire, Lexing- ton, Massachusetts) in the long term. Dr. Starr also said these latter medications can be used off-label for long-term suppression of visually significant SEIs, in addition to ste- roid pulses. Dr. Verdier said povidone iodine could be considered for EKC treat- ment. It doesn't carry much risk or expense, and it has shown promise against EKC infections in some studies. 4 Dr. Verdier tends to leave pseudomembranes alone in EKC patients, treating them with topical steroids instead. He will treat post- EKC dry eye with ocular lubricants and will consider off-label use of cyclosporine or tacrolimus for SEIs. appropriately in accordance with the condition. Dr. Mah said when it's clear it's a bacterial infection, he is quick to prescribe antibiotics. Research has shown that antibiotics are often inappropriately prescribed in some conjunctivitis cases. 1 Other research has shown that bacterial conjuncti- vitis is self-limiting and antibiotics could be avoided in those cases, too, but antibiotics can at least shorten the duration of the infection. 2 "I think it's prudent for the patient to begin antibiotic eye drops, and generally what I'll prescribe is a fluoroquinolone," Dr. Mah said, explaining that he'll start patients on a drop every hour or two, then taper to 3–4 times a day over a 5- to 7-day period. Viral conjunctivitis, without a specific medical therapy, is more supportive in nature. This to Dr. Mah means encouraging the use of artificial tears and lubricating eye drops and educating the patient on appropriate hygiene to avoid spread (washing linens frequently, not sharing towels, keeping common items like a TV remote disinfected, and avoiding touching one's eyes). If there is inflammation, a steroid drop could be used, but Dr. Mah cautioned that while it could help the symptomatology, studies have shown steroid drops can prolong the viral shedding, making the infec- tious process worse. Dr. Mah's treatment plan for EKC depends on the stage the patient is at. If the condition is relatively mild at the time without membranes, he tells the patient that, unfortunately, the symptoms will likely get worse before they get better. Patients need to be cogni- zant of their hygiene to prevent an epidemic within their home, school, or workplace, and should stay away from public places for about a week while the virus runs its course. If the patient is already present- ing with membranes, Dr. Mah thinks it is important to remove them because they could cause scarring of the conjunctiva. "Most of the time when you remove the membranes, it's uncomfortable in the office, but [patients] go home and feel a lot better," he said.

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