Disclosures Basic Management Guidelines Giant Papillary ...

The Great Mimickers
MOA 2011
Joseph P. Shovlin, OD, FAAO
Northeastern Eye Institute
Scranton, PA
Disclosures
Allergan Pharmaceutical Advisory Panel
AMO Global Medical Advisory Panel
-Acanthamoeba Outbreak Panel (ad hoc)
-Consultant
Bausch & Lomb Scientific Advisory Panel
-Global Steering Committee
-Panel On Fusarium Keratitis (ad hoc)
Ciba Vision Post-Market Surveillance Study Group
-Johns Hopkins Adjudication Committee (ad hoc)
Johnson & Johnson Global Professional Advisory Panel
Speaker’s Bureau: Vistakon, Ciba Vision,
CooperVision, Bausch & Lomb, AMO, Alcon,
Genzyme
Clinical Investigator (FDA): AMO, Ciba Vision,
Vistakon, Allergan, CooperVision
Basic Management Guidelines
• Generally best to remove contact lenses
immediately.
• Document condition carefully and should
photograph, if possible.
• Do not over-medicate but be sure to
address any infectious or significant
inflammatory process when indicated.
Contact Lens Complications That Mimic Non‐Lens Related Anterior
Segment Pathology
• Giant Papillary Conjunctivitis
• Contact Lens Induced Superior Limbic
Keratoconjunctivitis
• Contact Lens Related Pseudo-dendrites
• Contact Lens Related Acute Red Eye
Response and Infiltrates
Giant Papillary Conjunctivitis
• Similarties and differences with vernal
keratoconjunctivitis: size & shape of
papillae, symptomotology, corneal
findings
• Additional conditions to consider:
chlamydia, pyogenic granuloma, floppy eyelid
syndrome, lid imbrication, atopic keratoconjunctivitis,
molluscum contagiosum, sarcoid nodules, Wegener’s,
bacterial conjunctivitis

Contact Lens Induced Superior Limbic
Keratoconjunctivitis (SLK)
• Similarities/differences with Theodore’s SLK
(idiopathic): associated thyroid disease, bilateral
presentation, location & severity of conjunctival
findings, corneal features including stem cell
dysfuction
• Additional conditions to consider: lid meniscus
staining, epithelial splitting, herpes simplex
keratoconjunctivitis, chlamydia, episcleritis,
limbal follicles, sebaceous gland carcinoma
Management of GPC
• Always address the patient, lens and
wearing schedule.
• Suggested changes include replacement
cycle, material & design, accoutrement
and wearing schedule
• Pharmaceuticals: mast cell stabilizers
(type 1 response), NSAIDs, antihistamine/decongestants,
soft steroids,
lubrication

Case 7 ‐‐ corneal haze Stem Cell Deficiency

Contact Lens Related Pseudodentrites
• Similarities/differences with HSV keratitis:
raised/excavated, staining patterns, bilateral
presentations, adnexa features (skin involvement)
Additional conditions to consider: Richner-Hanhart
Syndrome (Tyrosinemia), Thygeson’s SPK,
edematous corneal formations, corneal verticilatta,
healing abrasions, stromal dystrophy,
medicamentosa, acanthamoeba keratitis
Management of CL Induced Superior Limbic
Keratoconjunctivitis
• Hiatus from lens wear
• Address patient, lens and wearing
schedule
• Frequent lubrication recommended
• Pharmaceuticals: steroid or
antibiotic/steroid combination for
inflammation, NSAIDs (limited value),
mast cell stabilizer, cyclosporine

Herpes Simplex Corneal Lesions
The early and late presentation
Case 14 ‐ painless Herpes Simplex
(not a classic dendrite)
Resolving Herpes Simplex skin lesions
on upper lid after 9 days
Both Stains ?? Additional Value

DIAGNOSTIC CONFUSION WITH
DENDRIFORM LESIONS OF THE CORNEA
• Acanthamoeba elevated corneal line
• Herpes simplex dentrite
• Herpes zoster keratopathy
• Contact lens “pseudo-dendrite”
• Thygeson’s superficial keratopathy
• Tryosinemia (Richner-Hanhart)
• Other corneal fascinations-edematous formations,
verticillata, filaments, stromal dystrophy, post PK
hypertrophic epitheliopathy

Differential Diagnosis of Ulcerative
Lesions
• Herpes simplex keratitis
• Neurotrophic keratitis
• Peripheral marginal infiltrates
• Chemical keratopathy
• Keratoconjunctivitis sicca
Management of Pseudodentrites
• Attempt to determine causea: Hypoxia,
antigen deposition, solution toxicity.
• Depending on the cause (if known):
increase oxygen flux, change solutions,
lubrication with lens wear, replace lens
more often.
• Pharmaceuticals: antibiosis (usually not
required), soft steroids, lubrication.
Contact Lens Associated Infiltrative
Keratitis (CLAIK)
• Is this really a different entity by
classification systems?
• Relative increase recently noted (Carnt,
Kislan, Keic)
• Disproportionate number of cases with
certain lens/solutions (combinations)
• Easily managed, but a nuisance to
patients and practices
Contact Lens Acute Red Eye Response
(CLARE)
A syndrome of conjuctival injection, infiltrative keratitis
and epitheliopathy
Multi‐factor etiology: hypoxia, trapped debris or
deposits, solution preservative, prolonged wearing time,
low grade bacterial response (bioburden), response to
mechanical trauma
Must rule out other lens or non‐lens related causes:
adenoviral keratoconjunctivitis, HSV keratoconjunctivitis,
Epstein‐Barr keratoconjunctivitis, Thygeson’s SPK,
ulcerative keratitis and other non‐specific responses.
Lipopolysaccharide Reaction
• LPS response to lens bioburden
• Toll-like receptors of the cornea are
involved
• Is there a disproportionate number of
these reactions with certain lens
type/MPDS combinations?

Factor Associated Not Associated
Known Association with CIEs
Improper lens care Bates 1989; Chalmers AAO 2004; Mah-Sadorra 2005; McNally, Chalmers ARVO 2004
Sankaridurg 1998
Lens Bioburden Holden 1996; Key 2000; Sankaridurg 1998; Sweeney ARVO 2003; Szczotka-Flynn IOVS 2010
Case contamination Bates 1989; Holden 1996; Sankaridurg 1998
Overnight/EW Bates 1989; Chalmers ARVO 2010; Cutter 1996; Donshik 1995; Efron 2005; Grant 1998; Mah-
Sadorra 2005; Morgan BJO 2005, IOVS 2005; Nilsson 1994; Santodomingo-Rubido 2007;
Stapleton 1992; Suchecki 1996; Vikoren 1990
Smoking Chalmers 2007 (trend); Cutter 1996; Morgan IOVS 2005; McNally 2003; Szczotka-Flynn IOVS
2010
No Association with CIEs
Suchecki 1996
Corneal staining Szczotka-Flynn Arch Ophthalmol 2007 Szczotka-Flynn IOVS 2010
PATH Carnt 2007 Willcox FDA 2008
Gender Morgan IOVS 2005 Chalmers 2007, OVS 2010; Forister 2009;
McNally 2003; Nilsson 1994; Sweeney
ARVO 2003; Szczotka-Flynn IOVS 2010
Rx Chalmers 2007 McNally 2003; Chalmers OVS 2010
No Conclusive Consensus
Age Chalmers AAO 2004, 2007, ARVO 2010; McNally 2003; McNally, Chalmers ARVO 2004 Morgan IOVS 2005; Sweeney ARVO 2003;
Szczotka-Flynn IOVS 2010
Lens care solution Carnt 2007, 2009; Chalmers ARVO 2010; Diec ARVO 2009, ARVO 2010; Kislan ARVO 2010;
Willcox FDA 2008
Soft contact lens material Brennan 2002; Carnt 2009; Chalmers 2010, ARVO 2010; Fonn 2002; Forister 2009 (trend); Keir
2010; Morgan BJO 2005, IOVS 2005; Santodomingo-Rubido 2007; Sweeney ARVO 2003; US
FDA, Bausch and Lomb 2001 (US); US FDA, CIBA Vision,2001; US FDA, Vistakon 2005 (US)
Solution/Lens
combinations
Donshik 1995; Morgan IOVS 2005;
Roseman 1994; Zigler 2007
Dillehay 2007; Efron 2005; Fonn 2002, US
FDA, CIBA Vision 2001 (US)
Carnt 2007, 2009; Keir 2010; Kislan ARVO 2010 Diec ARVO 2009; Zigler 2007
Mucin balls Carnt ARVO 2007; Sweeney ARVO 2003; Szczotka-Flynn IOVS 2010 (protective) Dumbleton AAO 1999; Tan AAO 1999
Season Chalmers OVS 2010; Morgan IOVS 2005
Duration of lens wear Chalmers 2007 Nilsson 2001
Swimming Chalmers AAO 2004 ; McNally, Chalmers ARVO 2004 Morgan IOVS 2005
Prior inflammatory event,
CL-related issues, or injury
Chalmers 2007; Ionides 1997; McNally 2003 Morgan IOVS 2005
Conjunctival or limbal
redness
Szczotka-Flynn Arch Ophthalmol 2007 Carnt 2007; Sweeney ARVO 2003
Risk Factor: Different SiHy Lens
Materials Similar in Most Instances
Factor Total Symptomatic
% of subjects % of CIEs* % of subjects % of CIEs*
Galyfilcon A 6.1% (4.7%) 14.3% (16.2%) 4.2% (3.1%) 17.9% (26.7%)
Senofilcon A 5.7‐9.9% (6.2%) 22.9% (27.0%) 2.5% (2.4%)‐5.6% 10.3% (20.0%)
Balafilcon A 0‐12.5% (5.9%) 22.9% (18.9%) 2.3‐5.7% (1.7%) 23.1% (13.3%)
Lotrafilcon B 4.1% (3.3%) 11.4% (13.5%) 1.5% (0.7%) 7.7% (6.7%)
Lotrafilcon A 2.4‐21.3% (7.4%) 28.6% (24.3%) 2.6‐9.9% (7.4%) 41.0% (60.0%)
*Percent of CIEs calculated when there are at least 3 comparison arms.
Brennan NA, et al. Ophthalmology. 2002;109:1172; Carnt NA, et al. Arch Ophthalmol. 2009;127:1616; Chalmers RL, et al. ARVO 2010; Poster
D815; Diec J, et al. ARVO. 2009;50:E-Abstract 5633; Fonn D, et al. Clin Exp Optom 2002;85:176; Keir N, et al. Cont Lens Anterior Eye.
2010;33:189; Kislan T, Hom MM. ARVO. 2010;51:E-Abstract 3424; Morgan PB, et al. Br J Ophthalmol 2005;89:430; Morgan PB, et al. Invest
Ophthalmol Vis Sci. 2005;46:3136; Nilsson SE, Montan PG. CLAO J. 1994;20:225; Santodomingo-Rubido J, et al. Eye Contact Lens.
2007;33:288; Sweeney DF, et al. ARVO. 2003;44:E-Abstract 3287; Szczotka-Flynn L, Diaz M. Optom Vis Sci. 2007;84:247; U.S. Food and Drug
Administration. PureVision visibility tinted contact lens. Bausch and Lomb November 20, 2001; U.S. Food and Drug Administration. CIBAVision
Focus Night and Day (lotrafilcon A) soft contact lens. October 12, 2001; U.S. Food and Drug Administration. Vistakon (senofilcon A) Contact
Lens. August 20, 2004.
Risk Factors for Corneal Infiltrates in
Szczotka-Flynn 2007 Study
In the study by Szczotka-Flynn and colleagues in 2007, the risk
for corneal infiltrates was 7-times greater in those with corneal
staining than for those without
However, for the subset of eyes with significant CIEs, no variables,
including corneal staining, were found to be significantly associated with
an infiltrative event of grade 3 or 4 on univariate or multivariate analyses
Szczotka-Flynn L, et al. Arch Ophthalmol. 2007;125(4):488.
Risk Factor: Lens Care Solutions
Factor Total 1,2 Asymptomatic 1 Symptomatic 1‐5
% of subjects % of CIEs % of subjects % of CIEs % of subjects % of CIEs
AQuify 11.7% 32.8% 6.6% 41.9% 4.6%‐5.1% 25.6‐29.8%
Clear Care 1.6‐3.3% 5.7% 1.2% 9.7% 0.4‐0.7% 2.6‐5.4%
Complete Easy Rub N/A N/A N/A N/A N/A 5.5%
Opti‐Free Express 5.1% 14.3% 3.0% 19.4% 2.0% 10.3%
Opti‐Free RepleniSH 16.8% 47.1% 4.6% 29.0% 10.2%‐12.2% 61.5%‐83.3%
Renu fresh N/A N/A N/A N/A N/A 11.1%
Renu • In sensitive a meta-analysis N/A of 4 comparable N/A studies: N/A N/A 0% 0%
6
• 0.5% of subjects using polyquad/Aldox-based solutions (both Opti-Free
Express and Opti-Free RepleniSH) experienced bilateral CIEs
• 0% of subjects using PHMB-based solutions (renu fresh, renu sensitive,
and Biotrue) experienced any CIEs
• However, several studies have found no difference in the rates of CIEs
regardless of preservative or formula used7-11 1. Carnt NA, et al. Arch Ophthalmol. 2009;127:1616. 2. Diec J, et al. ARVO. 2010;51:E-Abstract 1538.
3. Diec J, et al. ARVO. 2009;50:E-Abstract 5633; 4. Kislan T, Hom MM. ARVO. 2010;51:E-Abstract 3424. 5. Levy B, et al.
Cornea. 1997;16:274. 6. Reindel W, et al. BCLA. 2009;80:Poster 10. 7. Donshik PC, et al. Trans Am Ophthalmol Soc.
1995;93:49. 8. Dumbleton K, et al. Optom Vis Sci. 2006;83:758. 9. Morgan PB, et al. Invest Ophthalmol Vis Sci.
2005;46:3136. 10. Roseman MJ, et al. AAO. 1994;Poster 20. 11. Zigler L, et al. Eye Contact Lens. 2007;33:236.
Risk Factor: Lens/Solution Interactions
Factor Total CIEs: Lowest CL
Solution
SiHy
Total CIEs:
Highest CL Solution
Symptomatic CIEs:
Lowest CL Solution
Symptomatic CIEs:
Highest CL Solution
Galyfilcon A Clear Care = 2.1% RepleniSH =10.5% Clear Care = 0% RepleniSH = 7.9%
Senofilcon A Clear Care = 0% AQuify = 20.0% Clear Care = 0% RepleniSH = 64.8%
Balafilcon A Clear Care = 0% RepleniSH =10.3% Clear Care = 0% RepleniSH =17.9%
Lotrafilcon B Clear Care = 2.8% RepleniSH =7.3% Clear Care = 0% RepleniSH =4.9%
Lotrafilcon A Clear Care = 2.4% RepleniSH = 27.5% Clear Care = 2.4% RepleniSH = 27.5%
Carnt NA, et al. Arch Ophthalmol. 2009;127:1616; Diec J, et al. ARVO. 2009;50:E-Abstract 5633; Kislan T,
Hom MM. ARVO. 2010;51:E-Abstract 3424.
Case 5

Tarantula Hairs

Case 12

Confocal Microscopy: Fungal Keratitis

Confocal Microscopy:
Acanthamoeba Keratitis

MRSA
• MRSA must be a consideration in any external ocular
infection unresponsive to standard antibiotic therapy
over 2 weeks
• Suspicion for ocular MRSA must increase with:
– Malignancy
– Debilitating systemic disease
– History of ocular surface disorder
• Resistance to fluoroquinolones is increasing, even with
4 th generation
• Vancomycin and gentamicin remain effective
treatments
• Community-associated MRSA is an evolving ocular
pathogen most often found in “hospital-naive” patients
After 3 days of Abx
Pharmaceuticals For CLAIK/CLARE
• Appropriate hiatus from lens wear is
needed.
• Some controversy relative to need for
antibiosis (single agent v.
antibiotic/steroid combo.)
• Steroids applied with caution often help.
• Lubrication with un-preserved tears.
Pseudo‐membrane
Management of CLARE/CLAIK
• Attempt to narrow cause(s); must take a
careful look at patient’s lids.
• Provide frequently replaced or
disposable lenses with a reasonable
wearing schedule.
• Some consideration must be given to
solution changes (oxidative).
• Rigid lenses or refractive surgery may
be best alternative if multiple episodes
occur.
Quote of the Month
“If this is what I think it is, then I’m
dead wrong” Rev. Jim Ignatowski
(memorable character, Taxi, 1982)

• Thanks for attending!