1 Baroness Karen Christenze von Blixen-Finecke Germany – Cameroun - 1980 U N I V E R S I T Ä T S M E D I Z I N B E R L I N Conjunctival and Corneal Inflammation Uwe Pleyer, FEBO www 29-2-2020 Inflammation at the ocular surface Presence! Outline Basic mechanisms Impact on clinical management (DX, TX) Conjunctiva, Cornea Draining Tearways Lymphocyte Recircu- lation Tear- Gland Lid (margin) Lacrimal Functional Unit Neural Reflex- Arc Mod. from Knop E. In: Pleyer U. (Edt.) Entzündliche Augenerkrankungen. Springer, Berlin 2020 Ocular surface „defence system“
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Baroness Karen Christenze von Blixen-Finecke
Germany – Cameroun - 1980
U N I V E R S I T Ä T S M E D I Z I N B E R L I N
Conjunctival and
Corneal Inflammation Uwe Pleyer, FEBO
www 29-2-2020
Inflammation at the ocular surface
Presence!
Outline
Basic mechanisms
Impact on clinical
management (DX, TX)
Conjunctiva, Cornea
Draining
Tearways
(CALT)
Lymphocyte
Recircu-
lation
Tear-
Gland
Lid (margin)
Lacrimal Functional Unit
Neural
Reflex-
Arc
Mod. from Knop E. In: Pleyer U. (Edt.) Entzündliche Augenerkrankungen. Springer, Berlin 2020
Ocular surface „defence system“
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Dermott et al. Exp Eye Res. 2010; 90: 679–687. Mohammed I et al. Human antimicrobial peptides in ocular surface defense. Prog Retin Eye Res. 2017;61:1-22.
Defence – patter recognition - Toll Like Receptors (TLR)
Ocular surface – innate immune response
NF-kB translocation
Association of TLRs with Ocular Surface Diseases
Disease Toll Like Receptor (TLR)
Herpes Simplex keratitis TLR2,3,4,7,9
Pseudomonas keratitis TLR4,5,9
Fungal keratitis TLR2,4
Vernal keratoconjunctivitis TLR4,9
Atopic
Keratoconjunctivitis
TLR2
Sjögren’s syndrome TLR1,2,3,4
Non-Sjögren’s syndrome TLR2,4,5,9
Dermott et al. Exp Eye Res. 90: 679–687 (2010) Kiripolsky J, Kramer JM. Current and Emerging Evidence for Toll-Like Receptor Activation in Sjögren's Syndrome. J Immunol Res (2018)
Pepose JS et al. Randomized, Controlled, Phase 2 Trial of Povidone-Iodine/Dexamethasone Ophthalmic Suspension for Treatment of Adenoviral Conjunctivitis.
Am J Ophthalmol. (2018)
Conjunctivitis: TX
Clinical resolution
(PVP-I) 0.6% + Dexa. 0.1%
Adenovirus Conjunctivitis
Conjunctivitis
Kariwa H. et al. Inactivation of SARS Coronavirus Dermatology 2006;212:119–123
Entzündliche Augenerkrankungen. Springer, Berlin (2020)
Ocular Pemphigoid
Autoimmune disorder
Age: Mean 68 years
20-45% involves other mucosal sites
Diagnosis: Clinical! -> Staging I-IV
Immune histology!
Autoantibodies BP180 AG
Target structure = ß4 Integrin
May correlate with activity
Several mucosa sites: BP180 AG
Yasukochi A et al. Clinical and Immunological Studies of 332 patients.
Acta Derm Venereol. 96:762-7 (2016)
Chronic conjunctivitisMucous membrane pemphigoid
Conjunctivitis
Saw V P J Br J Ophthalmol 2013;97:1364-1367 *Rübsam A, Stefaniak R, Worm M, Pleyer U. Rituximab preserves vision in ocular MMP Expert Opin Biol Ther. (2015)
Microscopy: After smear and stainingShalchi Z et al., Antibiotic resistance in microbial keratitis: ten-year experience of corneal scrapes in the United Kingdom. Ophthalmology. 2011 Jin, H et al. Evolving risk factors and antibiotic sensitivity patterns for microbial keratitis at a large county hospital. Br J Ophthalmol. 2017; 101: 1483–1487
Bacterial keratitis – Medical therapy
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Bacterial keratitis – Medical therapy
Topical antibiotics
• According to antibiogram – otherwise empirically
• e.g. Ofloxacin (cave: high resistance rate) or
Moxifloxacin + Tobramycin
• Dosage
• According to findings: up to ¼ hourly and over 24 hours
• With intraocular involvement: I.V. dose
Mydriatics
• With intraocular involvement
Steroids (SCUT data)
• Topical administration only when the epithelium is closed
• Minimum amount required to achieve control of inflammation
Bacterial Keratitis Preferred Practice Pattern®; 2019: 126, 1–P55 (2019); Srinivasan, M et al. Steroids for Corneal Ulcers Trial Group.
Corticosteroids for bacterial keratitis: the Steroids for Corneal Ulcers Trial (SCUT). Arch Ophthalmol. 2012; 130: 143–150 Papaioannou, L et al. Corneal collagen cross-linking for infectious keratitis: a systematic review and meta-analysis. Cornea. 2016; 35: 62–71
Risks
•Shrinkage of the stroma
•Refraction changes
•Increased scarring
•Perforation
Bacterial keratitis – Surgical therapy I
Cross linking
•in moderate bacterial ulcers
• in more anterior stromal infections
•faster reepithelialization
•can block corneal melting
Foto
Acanthamoeba keratitisClinic
• Young, healthy patients; contact lens
• Mostly one-sided disease / insidious onset
• Severe pain -> (peri-)neuritis
Slit-lamp
Early stage (2 weeks – superficial)
• Dirty epithelium
• (Pseudo-) dendritic changes (HSV-like)
• Limbitis
Middle stage (2-6 weeks – stromal infiltration)
• Spread along the nerve fibers (perineuritis -> pain)