Case report: Marginal keratitis symptoms recur with itchy eyelids
When managing an irritated cornea, choosing among fortified antibiotics, oral antivirals, anti-inflammatories or combination therapy as the best course of action can be challenging.
Brandon D. Ayres, MD, Jennifer Loh, MD, Jai G. Parekh, MD, MBA, Henry Perry, MD, and William B. Trattler, MD, discussed a case of marginal keratitis in a patient who later experienced ocular surface irritation, itchy eyelids and lid crust after treatment.
Source: Jai G. Parekh, MD, MBA
Parekh: A 71-year-old man had symptoms of pain, redness and watering in the right eye with blurry vision in both eyes over several weeks. He was treated with an antibiotic somewhere else, a topical antiviral, thinking it was herpetic, and also artificial tears. What is your diagnosis?
Trattler: I see a bit of white infiltrate, so it appears to be peripheral inflammation (Figure 1). It is hard to know for certain if this is infectious or not at this point, so my next step would be to use fluorescein dye.
Parekh: You mentioned infection here. Do you think it is going to be entirely infection? The patient has had this now for quite some time.
Trattler: Usually, it is inflammatory.
Parekh: What do you do next? Pull out fortified antibiotics, oral antivirals or combination therapy including steroids (topical)?
Trattler: Typically, these cases do well with anti-inflammatory drops (topical steroids) because this appears to be chronic inflammation. It is persistent. I would also use an antiseptic spray such as hypochlorous acid spray, which will help eliminate any localized organisms.
Perry: I have thoughts about combination therapy. I am 100% against that because almost any time you see any type of inflammation like this, there is a good chance it could be herpetic. There is no reason to use combination therapy in this particular setting.
A lot of times, the inflammatory component will get better by treating the ocular surface with lid hygiene and artificial tears, and then you can reevaluate it. The majority will probably get better within a week or two with that therapy. If that does not work, then I would do other investigations.
Ayres: When we have patients who have this kind of chronic, ongoing lid margin disease and marginal keratitis, you have watch out for things like rosacea, blepharitis, Demodex and staphylococcal marginal keratitis. And we do not love combination medications. We like to split them apart. Look at the lids, see what you think you have and then maybe add some antibiotic. Then I would probably add anti-inflammatory separately so you can independently regulate your antibiotic and your anti-inflammatory.
Parekh: At times there is a reticence to use steroids, but I agree. We do a thorough exam to make sure there is no viral component. Like you said, Dr. Perry, using an anti-inflammatory could be appropriate.
That is what this patient got, and he improved as time went on. Actually, he went onto combination therapy (antibiotic/steroid) and had resolution of the marginal keratitis. Then we saw the patient back, and 10 days later, he had almost a recurrence of the symptoms but now with complaints about itchy eyelids (Figure 2). Years ago, maybe we would do nothing about it, but now we have something to take care of these patients, and we are all doing a better job at having patients “looking down.”
The patient had intermittent ocular surface irritation, the marginal keratopathy resolved, and he also had lid crust. In the good old days, we would call this maybe staph or scurf and treat it with combination therapy, baby wipes, tea tree oil and so forth. But Dr. Ayres, you mentioned something on your differential. You are having the patient “looking down,” and the patient has these funny lesions at the base of the lid margin. What are your thoughts?
Ayres: If you have what we now would call collarettes, traditionally, in my office we would start plucking those lashes to look for Demodex. But we do not have to do that anymore, and if I see collarettes in the clinical scenario, it fits nicely for chronic Demodex blepharitis, so I am going to put this patient on Xdemvy (lotilaner ophthalmic solution 0.25%, Tarsus Pharmaceuticals).
Parekh: Collarettes represent feces and “other matter” of the mites, and it is pathognomonic. The FDA required that in the trials with Tarsus and the use of lotilaner. In the old days, we would maybe trim eyelashes and use baby shampoo or a bland or antibiotic eye ointment. Now we have Demodex-tailored therapy. Dr. Loh, any thoughts on Demodex-tailored therapy? What are you doing these days?
Loh: Great question. I think I would definitely go with the new FDA-approved lotilaner. But I also think there is value in using a hypochlorous spray or tea tree oil as well, especially if it takes a while for the patient to get the medication. But I have been moving more toward lotilaner for a cure.
- For more information:
- Brandon D. Ayres, MD, of Wills Eye Hospital in Philadelphia, can be reached at bayres@willseye.org.
- Jennifer Loh, MD, of Loh Ophthalmology Associates in Miami, can be reached at jenniferlohmd@gmail.com.
- Jai G. Parekh, MD, MBA, of EyeCare Consultants of NJ, can be reached at kerajai@gmail.com.
- Henry Perry, MD, of OCLI Vision in New York, can be reached at hankcornea@gmail.com.
- William B. Trattler, MD, of the Center for Excellence in Eye Care in Miami, can be reached at wtrattler@gmail.com.
Click here to read the Cover Story, “Expert panel tackles challenging cornea cases.”
Collapse
Read more about