Episode 116
116: StAR: Ocular Infections
This StAR episode features the CID State-of-the-Art Review on Ocular Infections.
Our guest stars this episode are:
Miriam Barshak (Massachusetts General Hospital; Mass Eye and Ear)
Akash Gupta (University of Pittsburgh Medical Center)
Journal article link: Barshak MB, Durand ML, Gupta A, Mohareb AM, Dohlman TH, Papaliodis GN. State-of-the-Art Review: Ocular Infections. Clin Infect Dis. 2024;79(5):e48-e64. doi:10.1093/cid/ciae433
Journal companion article - Executive summary link: https://academic.oup.com/cid/article-abstract/79/5/1125/7906419
From Clinical Infectious Diseases
Episodes | Consult Notes | Subscribe | Twitter | Merch | febrilepodcast@gmail.com
Febrile is produced with support from the Infectious Diseases Society of America (IDSA)
Transcript
Hi, everyone.
2
:Welcome to Febrile, a cultured podcast
about all things infectious disease.
3
:We use consult questions to dive into
ID clinical reasoning, diagnostics,
4
:and antimicrobial management.
5
:I'm Sara Dong, your host
and a MedPeds ID doc.
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:Today, we have another State of
the Art Review or StAR episode
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:talking about ocular infections.
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:So let me start by
introducing our guest stars.
9
:We'll start with Dr.
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:Miriam Barshak, who completed her medical
internship and residency at Brigham
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:and Women's Hospital, followed by I.
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:D.
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:fellowship in the combined
Massachusetts General Hospital
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:& Brigham and Women's Hospital I.
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:D.
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:fellowship program.
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:She then devoted 10 years to basic
research in streptococcal pathogenesis
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:before transitioning to a primarily
clinical role at Massachusetts General
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:Hospital and Massachusetts Eye and Ear.
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:There she serves as a primary I.
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:D.
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:consultant for Mass.
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:Eye and Ear.
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:Miriam Barshak: Hi, thanks
so much for having us.
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:Sara Dong: Our other
guest star today is Dr.
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:Akash Gupta.
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:He was Dr.
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:Barshak's ID clinic fellow at
Massachusetts General Hospital,
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:and she taught him everything he
knows about ocular infections.
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:Prior to fellowship, he was an
internal medicine pediatrics
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:resident at Massachusetts General.
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:After fellowship, Akash practiced ID
in northern Massachusetts, and since
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:August 2024, he joined the University
of Pittsburgh Medical Center, where
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:he is a clinical assistant professor.
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:Akash Gupta: Uh, hey, this is Akash.
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:Happy to be here.
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:Sara Dong: All right, as everyone's
favorite cultured podcast, we love
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:to ask our guests to share a little
piece of culture, just something
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:that you have enjoyed recently
or that has brought you joy.
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:Miriam Barshak: Yeah, I'll go first.
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:So, on a family vacation over the
recent December holiday break, we
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:went to this amazing place in St.
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:Augustine, Florida called
the Museum of Tiny Art.
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:So, instead of looking at bacteria under
microscopes, you can go from scope to
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:scope to look at these miniature paintings
that all fit inside the head of a needle.
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:Sculptures and paintings and all kinds
of other incredible things that people
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:do with microscopes that are unrelated
to what we usually think of them for.
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:Sara Dong: That sounds so delightful.
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:Miriam Barshak: Yes.
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:One of them was a carving on
a strand of hair that you can
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:look at under the microscope.
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:It's kind of incredible to
imagine how much effort must
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:have gone into doing that.
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:Sara Dong: Yeah, that's awesome.
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:What about you, Akash?
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:Akash Gupta: Um, do
hobbies count as culture?
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:Sara Dong: Mm hmm.
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:Akash Gupta: Um, so I'd say,
like, the main thing I have gotten
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:totally obsessed with over the
last couple years is birding.
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:Following many in our ID department,
I, um, kind of took a plunge.
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:I had a passive interest for years,
and then two years ago, my brother in
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:law kind of got me hooked on a trip to
Costa Rica that we took as a family.
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:Um, and then I've just kind of
gotten completely insane, and it's
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:been a really fun part of my life.
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:Um, I recently moved to Colorado where,
where the birding has been great.
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:Um, but I had to link it to like
more conventional cultures, I guess
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:I would say, there's a book or a
series of books by Jen Ackerman,
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:who writes a lot about like sort of
bird behavior and bird intelligence,
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:um, and like migration and stuff.
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:And they're just super fascinating.
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:Um, and there's a feel good movie
that I think a lot of us need right
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:now called The Big Year, which
I watched a couple of weeks ago.
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:Um, that, uh, that was delightful.
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:Sara Dong: Lovely.
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:I like that you had a couple
different picks for us.
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:Um, well, thank you guys so
much for creating this article.
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:We're going to be talking about
ocular or eyeball infections today.
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:You address and highlight a lot of the
common challenges we have in ID when we're
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:co managing these patients, whether that
is, you know, the exam and anatomy of the
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:eyeball, the infections or the treatment
options that we have, or even if it's
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:just deciphering the ophthalmology note.
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:We're gonna have a couple rapid fire
cases today, but before we start, I
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:thought it might be helpful to have
you share maybe just a little bit about
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:creating the article, what you guys
were thinking about and or some of your
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:experiences treating ocular infections.
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:Miriam Barshak: Yeah, so, um, I was
very excited to be asked to write this
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:article recognizing that there is a, uh,
great amount of need for something that
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:kind of bridges the language and the
concepts of ophthalmology to ID doctors
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:who individually probably don't see
that many infections in the course of a
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:career, unless they work at a location
like ours, where I am at Mass Eye and
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:Ear, where we are incredibly privileged
to work really closely with amazing and
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:thoughtful ophthalmologists and be able
to access their notes and the photos
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:that they take of the eyes that they're
taking care of and to see all of the
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:work up and be able to collaborate in
managing this area of infections that
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:is in some cases a world of its own.
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:But in other cases, it's very intimately
connected with the rest of the body
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:and the rest of the infections that we
see, so it's been a really incredible
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:professional experience for me.
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:And certainly there have been some really
memorable cases in which the first inkling
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:that there was something systemic going
on was in the eye or the first opportunity
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:to make a diagnosis of a systemic
process that was otherwise undiagnosed
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:was through taking advantage of that
opportunity to have ocular sampling done.
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:It's very rewarding.
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:Akash Gupta: I guess I
can add just a little bit.
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:I mean, a lot of my experience just
comes through working with Miriam.
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:I was, um, lucky enough to have
her as my clinic preceptor.
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:And so that was just kind of a step
into this like, um, wild world of eye
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:infections that I think I would have had
a lot less familiarity with otherwise.
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:And I think what maybe stood out
is just the really, really positive
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:collaborative relationships that
Miriam had with the ophthalmologist
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:and, um, the ongoing discussions and,
like, how much exam really matters.
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:And, and it's exams that we
can't typically do ourselves.
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:And so it's just really
like a full partnership.
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:And I think the stronger that partnership
is, the easier it is to manage these.
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:Sara Dong: Great.
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:And even though there are a lot of
people who might be multitasking while
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:they listen to Febrile, maybe they're
in the car or they're walking their
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:dog, um, I do want to direct everyone
to the awesome figures that are in
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:the paper, thinking about anatomy.
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:And so even without us having that visual
in front of us, could you give us an
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:overview of the way that you think about
the anatomy of the eye and infection?
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:Akash Gupta: So I can take the first stab
at this, um, and I will say, you know,
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:for everything I, I take the first pass
on, um, I'll, I'll let Miriam comment just
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:cause she has vastly more expertise than
I do, but the way she taught me to think
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:about it and the way I've kind of tried
to think about it before, so I, I guess,
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:you know, one thing is that actually often
when I have eye infection cases, I will
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:actually look at the anatomy again, like
I'll pull it up on Google or whatever.
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:Now I'm pulling it up on this
review article because it's a little
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:more specific, but there's kind
of two ways that I think about it.
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:One is outside in, and then
the other is sort of anterior,
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:posterior, or front and back.
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:So the layers going outside in, and if
you guys do have, if listeners do have the
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:paper pulled up, it would be Figure one.
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:So from the outside, we have this layer
called the sclera, and that's kind of the
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:white part of the eyeball that you see.
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:And the sclera is continuous in the
front with cornea, where It's kind of an
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:opening that lets you, uh, lets light in.
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:And so that outer layer, uh, sclera,
if it gets inflamed is called
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:scleritis, which is kind of intuitive.
140
:Um, what is less intuitive is that if you
inflame the cornea, it's called keratitis.
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:And then, uh, there is a layer called the
conjunctiva, which is probably the the
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:area that most people are familiar with
because they you know, see it in common
143
:practice, but the conjunctiva is basically
a mucous membrane that covers part of
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:the sclera up to its junction with the
cornea and then reflects onto the inner
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:eyelid, and we call inflammation of that
conjunctivitis, which is again intuitive.
146
:Um, so the next layer
inside is called the uvea.
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:And we call inflammation of anything in
this layer and sort of the areas around
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:it, um, uveitis, and it's actually
three different structures that form it.
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:Um, the iris is in the front, which
controls the size of the pupil, and
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:a lot of people are familiar with,
and when that's inflamed, it's called
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:the iritis, and then behind it is the
choroid in the posterior part of the
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:eyeball, and the inflammation of that
is called a choroiditis, and that can
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:end up being a pretty important finding
for a few different infections, and then
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:in between you have the ciliary body,
which connects them together, and that
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:is called cyclitis if it is inflamed.
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:And then finally, the medial
layer we get is the retina, which
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:many of us are familiar with, and
that's how we get light perception.
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:And if you inflame that
area, it's called retinitis.
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:It also has a blood eye barrier
at the retina that's kind of
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:similar to the blood brain barrier,
which ends up being relevant.
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:So that's kind of the inner to outer
dimension, and then we can think
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:about the front and back dimension.
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:So in the, um, anterior part of the eye,
we have something called the anterior
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:segment, which is everything from the
lens forward, basically, between the
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:cornea and the lens, and it's filled
with something called the aqueous humor.
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:And then in the back of the eye, we have
the posterior segment, which is between
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:the, uh, lens and sort of back of the eye,
and it's filled with the vitreous humor.
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:So, uh, we call that vitritis if
it gets inflamed, and then, um,
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:inflammation of aqueous humor
is, uh, little more complicated.
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:But if you do see inflammatory cells
there, that's often what we call anterior
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:uveitis or as a sign of anterior uveitis.
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:Miriam, anything to add?
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:Miriam Barshak: No, I think
that was a really great summary.
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:I was going to jump in with a couple
of specific terms in the glossary
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:that can be confusing for people
that don't see them regularly.
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:And just to start by way of background,
I think all of, all of us are familiar
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:with the Snellen eye chart where there
were a whole bunch of letters at the
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:top, starting with a big letter E.
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:So people who can see that big letter E,
but nothing smaller than that have 20 over
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:200 vision, um, but the ophthalmologists
have more specialized ways of
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:distinguishing lower levels of vision.
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:And those are things that are really
important for us to know about because
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:often that's kind of one of the eye vital
signs is what the vision itself is like.
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:And it gives you a sense about how severe
a vision threatening infection might be.
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:So for people that can't see the big
E, but can count fingers that you'll
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:hold up in front of their face,
that's called count fingers vision,
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:which would be designated as CF.
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:The next level down, if they can't
count fingers, would be to determine
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:whether they can see motion.
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:So moving your hand in front of
their face, if they can tell when
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:it's moving and when it's not,
then that's hand motion vision.
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:If they can't see hand motion, then
you can test for light perception
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:with a pen light and see if they can
localize the light in different areas
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:or tell whether the light is on or off.
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:If they can, then they have light
perception vision, and if they can't,
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:then they have no light perception NLP.
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:And as you might imagine, NLP is not
only the most undesirable of all those
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:vision options, but it is also the most
ominous, because often once there's
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:no light perception, there's a lot
less hope for regaining the vision.
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:As long as there's some vision, even if
it's only light perception, there are a
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:lot of reasons why the vision may be that
poor, many of which may be reversible.
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:It may be that there's a lot of edema
or a lot of inflammation that's, um,
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:treatable, and so definitely they tend
not to give up on eyes as long as there's
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:light perception, but once there's no
light perception and they don't think
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:there's visual prognosis for the eye,
then the, um, options that are used for
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:trying to treat infections are a bit
different in level of aggressiveness.
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:So those are the abbreviations
for visual acuity.
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:Some of the helpful abbreviations related
to the anterior eye exam that you may see.
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:So in describing the cornea, um, you may
see something that's designated as PK.
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:That's a common one and it stands
for penetrating keratoplasty.
211
:So that is the ophthalmologic
term for a corneal transplant.
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:So the cornea, that's the native cornea
has been removed and a new cornea has
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:been placed, whether it's a natural
cornea or an artificial cornea, those
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:get designated the same way as PK.
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:Not to be confused with PK as KP, keratic
precipitates, so those are kind of clumps
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:of inflammation from the aqueous that are
walled up against the back of the cornea.
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:And that indicates the inflammatory
process going on in what's called
218
:the anterior chamber, the space
between the cornea and the iris.
219
:Um, the AC is the designation
for the anterior chamber.
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:And again, that's between
the cornea and the iris.
221
:And when they describe the exam
of the AC, they refer to, um,
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:flare, which is protein, and
cells, which is white blood cells.
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:And those get scaled on a scale from
one to four, depending on how much flare
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:and how much cells being seen there.
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:Um, moving further back,
there's a, um, abbreviation.
226
:PC IOL that you might see.
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:So that's a lens.
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:And the PCIOL stands for posterior
chamber intraocular lens.
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:And that refers to a lens that's been
placed during a cataract surgery.
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:So if someone has one of those lenses,
it means by definition, their eye
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:has been surgically operated on.
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:And, you know, from the infection
standpoint, it means there's an
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:opportunity for having introduced
infection and also a site perhaps
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:for a nidus of infection to hang out.
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:So something specific about it.
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:And then the posterior eye exam.
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:They often describe cells in
the vitreous if it's inflamed.
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:There's an abbreviation PPV, pars plana
vitrectomy, so that's the descriptor
239
:that's given to the, um, removal
of the vitreous, which is something
240
:that's done sometimes for diagnostic
and sometimes for therapeutic reasons.
241
:Um, in the retina, there's often a
description of the macula, so, um,
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:the macula gives central and sharp and
color vision, and the peripheral areas
243
:of the retina are more important for
low light and peripheral vision, and
244
:that is important because infection
involving different areas of the retina
245
:may lead to different, um, degrees of
symptoms and types of visual symptoms.
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:And then lastly, in the, in the glossary,
I wanted to highlight the imaging studies
247
:that the ophthalmologists commonly
use to work out various processes.
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:The most common one you'll see
described is called a B scan.
249
:B stands for brightness,
little counterintuitively.
250
:Um, but that's an ultrasound, so it's
basically an ultrasound of the eye.
251
:And on a B scan you can see inflammation
in the vitreous or areas they may
252
:not be able to see into directly with
the regular eye exam, particularly if
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:there's a lot of inflammation in the
front part of the eye, the ultrasound
254
:may be better at visualizing that.
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:And it can also help
identify retinal detachment.
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:And then lastly, there are some
angiography procedures that are used
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:in ophthalmology for elucidating
whether there's inflammation
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:going on in the blood vessels.
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:And those studies get referred to as
FA, fluorescence angiography, or ICG,
260
:which is a different kind of angiography
that looks at the cord and retinal
261
:vasculature, which can be helpful
in making various diagnoses on exam.
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:Sara Dong: Great.
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:Yeah, I was going to show my vulnerability
and just say that when I see these
264
:abbreviations, even if I feel, uh,
pretty certain that I know what they
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:are for things like OD (oculus dester,
right eye), OS (oculus sinister,
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:left eye), I often will go and double
check and Google it to make sure
267
:I'm not misinterpreting information.
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:Um, so now everyone has a resource
in Table 1 that summarizes all these
269
:terms into the reference glossary.
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:Akash Gupta: Can I make
one additional plug?
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:Um, there was a website that I found
while I was Miriam's fellow that
272
:I used to help prep for clinic,
and it's called, um, eyeguru.org
273
:and simply eyeguru.org/translater,
274
:and it's literally an
ophtho note translator.
275
:Um, so you can put in, like, terms
or strings of terms or phrases
276
:that you see in an ophtho exam or
something, and it will turn it into,
277
:like, understandable prose for you.
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:Um, so I, that is
something I've used a lot.
279
:I don't know if, you know, as AI
develops, that will become less
280
:specifically relevant, but for
now it's still been very useful.
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:Sara Dong: Excellent.
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:Yeah, I will put a link to
it in our consult notes.
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:Um, all right.
284
:Well, you guys are up today to talk
us through a couple different rapid
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:fire ocular infection cases so we
can get some pearls, some learning.
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:All right.
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:And so I'll get us started.
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:We have a 73 year old woman who presents
with two days of left eye watery drainage,
289
:redness, pain, and visual changes.
290
:She also has five days of a
vesicular rash on the left forehead.
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:On gross examination, there is
conjunctival injection, and the
292
:slit lamp exam shows corneal
edema with pseudodendritic
293
:lesions and fluorescein staining.
294
:So what are we dealing with here?
295
:Miriam Barshak: Right, so whenever
we hear about redness of the eye, um,
296
:many non specialists initially think
of conjunctivitis because that is
297
:certainly the most common infectious
cause of redness of the eye, but
298
:conjunctivitis doesn't usually come
along with pain and definitely doesn't
299
:come along with visual changes.
300
:Those are things that make you
need to think about something else.
301
:And especially knowing that there's
a vesicular rash on the forehead.
302
:That's kind of the, um, the strong
suggestion that there may be a viral
303
:process going on, probably zoster,
dermatomal zoster, which in the V1
304
:distribution has an associated risk of
involving various structures of the eye.
305
:Classically with that, um, we advise that
patients should get an eye exam, even
306
:if they don't have ocular symptoms, but
if they do have ocular symptoms, then
307
:they should have a very prompt eye exam.
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:The treatment of ocular involvement
with herpes zoster requires more
309
:than just systemic antiviral therapy.
310
:So the most common, um, eye involvement
that does get seen in these types
311
:of patients is some combination
of conjunctivitis and keratitis.
312
:And when you put this together,
you get keratoconjunctivitis.
313
:Just in, in general, when we think
about conjunctivitis, there are other
314
:much more common viral causes of
conjunctivitis, the most common one
315
:being adenovirus, and conjunctivitis in
adults in general is most commonly viral.
316
:So adeno is often at the top of
the list, not in this case, but in
317
:most otherwise healthy patients.
318
:Again, that's not usually
vision threatening.
319
:And diagnostically, it's
often a clinical diagnosis.
320
:Think about watery drainage, but really
that doesn't necessarily have the
321
:greatest sensitivity or specificity
and in better careful studies, there
322
:are other factors that can help you be
more confident about that diagnosis.
323
:Things like having a lot of itching,
having having contacts with other
324
:people or having other viral symptoms
that may go along with having an
325
:adenovirus syndrome, having a runny
nose or other sorts of, um, of symptoms.
326
:Bacterial infections in adults of the
conjunctiva are relatively uncommon, um,
327
:but in children, bacterial infections
of the conjunctiva are much more
328
:common than the most common bacteria.
329
:Bacteria wise conjunctivitis include
pneumococcus, staph aureus, and H.
330
:flu in adults.
331
:As I mentioned, bacteria are much less
common, but of course, the only way
332
:to get a clear diagnosis of what it
is that you're treating as a bacterial
333
:infection would be to get a culture.
334
:Keratitis, in general, is more commonly
caused by bacteria than by viruses.
335
:So our case is a viral infection, but to
put that aside for a moment, most of the
336
:cases of keratitis you're likely to come
across are bacterial and the primary risk
337
:factor for keratitis is contact lens use.
338
:And when I say contact lens use,
what I really mean is lapses in
339
:hygiene associated with contact
lenses, which are really common.
340
:Um, anyone who wears contact lenses
may know how common it is to maybe
341
:not change the case as frequently as
you should or just sleep in them, um,
342
:or not change them out as frequently
as they're supposed to be changed.
343
:So this aspects of hygiene may explain why
the rates of keratitis are so strongly
344
:associated with contact lens use, but
there are other risk factors as well.
345
:And those are things like ocular
trauma or dry eye or other surface eye
346
:disease, which provides a nidus by which
bacteria can set in and cause infection.
347
:They're most common symptoms of
keratitis involved pain in the eyes.
348
:So the idea that this patient's
having pain certainly goes along
349
:with having corneal involvement.
350
:Sometimes, often there's also
redness and sometimes there's also
351
:visual changes because the cornea
has such an important role in being
352
:transparent and refracting light.
353
:Any pathology in the cornea can
really seriously impact vision.
354
:On exam, the easy part of the exam
was a pen light that all of us can do.
355
:You may see an opacity where there may
be a defect in the cornea, and you may be
356
:able to see a hypopyon, which is a layer
of pus in the anterior chamber that's
357
:spaced between the cornea and the iris.
358
:In patients with keratitis, those
collections are kind of sympathetic to
359
:what's going on in the cornea, and the
collection itself is usually sterile.
360
:You can see that better on a slit lamp
exam if it's a very small collection.
361
:And the slit lamp also allows you to
see deeper into the eye to make sure
362
:that there's nothing going on more
deeply than the anterior chamber.
363
:The microbiology of keratitis when
it's bacterial is most commonly
364
:things like Staph and Pseudomonas.
365
:For viral infections, as I mentioned,
keratitis in this particular case,
366
:is caused by herpes viruses, and
those are the most common causes
367
:of viral keratitis that you see.
368
:Fungal infection is a really important
cause of keratitis, particularly in
369
:less developed places, where a lot of
the risk for infections in the cornea
370
:are from trauma, and often trauma
associated with agricultural work,
371
:for example, or other environmental
exposures rather than contact lens use.
372
:And then Acanthamoeba is an
organism, parasite, that we see, um,
373
:particularly associated with having
unclean water in contact lens cases.
374
:Usually treatment for
keratitis is topical therapy.
375
:Empirical treatment for bacteria
usually is trying to cover the
376
:bases of staph and pseudomonas.
377
:So usually things like quinolone or
vancomycin in combination with tobramycin.
378
:Um, if there's concern for fungal
infection, then topical antifungals
379
:and natamycin is a frequent choice
that the ophthalmologist will make.
380
:Acanthamoeba has its own, uh, planned
regimen, and typically these types
381
:of infections do get better with
topical therapy, but if they don't,
382
:then there are a whole series of
maneuvers that the ophthalmologist can
383
:do, including various types of light
therapy and including cross linking.
384
:And, um, ultimately, if those things don't
work out well, then patients sometimes
385
:wind up needing a corneal transplant
in order to debulk the infection.
386
:And then they can get it into
a cornea placed, um, and once
387
:the infection has settled down.
388
:For viral cases like this one, the
treatment involves systemic antiviral
389
:therapy for the forehead involvement
with the zoster and topical antiviral
390
:therapy, um, for the eye involvement,
although it depends a bit on how
391
:deep the corneal involvement is.
392
:Cornea has a surface component, the
epithelium, but it also has a stromal
393
:component, and so depending on how
deep the involvement is with the,
394
:um, with the cornea, the appropriate
treatment for the eye itself may include
395
:topical antivirals or oral antivirals.
396
:Um, and then for stromal infiltrates,
they usually also include topical
397
:steroids for trying to control the
inflammation in the cornea that's
398
:impacting the vision so much.
399
:The prognosis for viral infections of
the cornea like this one is not great.
400
:So, um, 50 to 60 percent of people will
wind up with corneal scarring after an
401
:episode of corneal involvement with VZV.
402
:And along with the scarring often
comes anesthesia, which means that
403
:they can't necessarily feel that next
episode of bacterial superinfection
404
:that may follow at some point.
405
:So these patients have an elevated
risk of subsequent corneal infections
406
:that can lead to ulceration and
ultimately perforation if they don't
407
:recognize what's going on and aren't
able to present for care fast enough.
408
:So understandably, um, one of the
biggest goals from the corneal infection
409
:standpoint is to try to prevent these
episodes, um, using vaccination for
410
:VZV, uh, and using chronic acyclovir
for recurrent episodes of HSV.
411
:Um, and then obviously contact
lens hygiene strategies to try
412
:to minimize the risks of other
types of non viral keratitis.
413
:Sara Dong: Great.
414
:And just to orient people again
and summarize, we've just talked
415
:about conjunctivitis and keratitis.
416
:If you think back to when Akash
was talking through those layers,
417
:he mentioned the sclera, the
cornea, and the conjunctiva.
418
:Alright, well, we will jump
into our second case now.
419
:We have a 25 year old woman with
a history of injection drug use.
420
:She presents with pain and deteriorating
right eye vision over the past month.
421
:She's had no fever, sweats,
or other systemic symptoms.
422
:Her visual acuity is
20/400 OD and 20/20 OS.
423
:The fundoscopic exam reveals a white
lesion in the vitreous, and she's
424
:diagnosed with endogenous endophthlamitis.
425
:Intravitreal injections of vancomycin,
ceftazidime, and voriconazole are
426
:given, and blood cultures are drawn.
427
:So what organisms are you thinking
about and most worried about here?
428
:Akash Gupta: I think in this patient I
would be most concerned about a fungal
429
:etiology for a few different reasons.
430
:One is that it's a sort of a
community acquired infection with
431
:the main risk factor being injection
drug use, which does increase the
432
:likelihood of a candidal etiology.
433
:And then there's also a subacute course
of symptoms rather than over a few days.
434
:It seems like it's been over a
week to a month, and that also
435
:increases the likelihood of candida.
436
:And I think just taking a
step back to kind of how we
437
:think about endophthalmitis.
438
:So endophthalmitis basically refers
to any intraocular infection, but
439
:we kind of colloquially or generally
use it to refer to a bacterial or
440
:fungal infection that involves either
the vitreous or the aqueous humor.
441
:And there's two types of endophthalmitis.
442
:The most common by far actually is
exogenous endophthalmitis, where
443
:pathogens get introduced from the
ocular surface, like basically from
444
:trauma, bringing pathogens outside in.
445
:That can either be due to direct ocular
trauma, which is more common in non U.
446
:S.
447
:countries, or it could be as
a complication of some type
448
:of eye procedure or surgery.
449
:These are actually the ones that we have
a lot less familiarity with because the
450
:vast majority of these are managed without
infectious disease input and are just
451
:entirely managed by the ophthalmologist.
452
:And so the other type is endogenous
endophthalmitis, where the, the
453
:etiology is likely hematogenous spread
without any sort of ocular trauma
454
:that would bring the pathogen inside.
455
:These are actually only about 15 percent
of endophthlamitis cases, but they're
456
:the ones that we see as ID practitioners
far more and get called to help
457
:treat primarily because they're often
associated with a systemic infection.
458
:In addition to the direct eye
symptoms, which would include eye
459
:pain and decreased vision, you can
get systemic symptoms, which are more
460
:common in endogenous than exogenous.
461
:But even in endogenous, they don't
happen in everyone, and, you know,
462
:this, uh, young woman, despite having
three, maybe four weeks of symptoms,
463
:actually didn't have systemic
symptoms, um, uh, despite probably
464
:seeding from a hematogenous source.
465
:So there are a variety of common
bacterial pathogens that we see,
466
:including Staph aureus, Strep, um, we
also see some gram negatives such as E.
467
:coli, and then there have been, um, a
fair amount of cases of the hypermucoid
468
:viscous klebsiella seeding the eye
in addition to the other abscesses
469
:that it forms throughout the body.
470
:Um, and in these, uh, bacterial
etiologies, usually the symptoms are
471
:pretty acute between one and a few days.
472
:And then in contrast, candida is more
subacute, as I mentioned, and has a
473
:higher risk of intraocular seeding, um,
if you have candidemia, then bacteremia.
474
:And the risk factors for inpatients
are kind of similar to what you think
475
:for of candidemia: people in the
ICU for a long time with lines, maybe
476
:immunocompromised, um, but among
outpatients, the major risk factor is
477
:injection drug use, which fits this case.
478
:Among people with injection drug use
related endophthalmitis in one series in
479
:Boston, 59 percent were candidal etiology.
480
:So it is the majority
of these kinds of cases.
481
:In summary, for this case, I would
say that she has subacute onset of
482
:ocular symptoms, absence of systemic
symptoms, and evidence of endogenous,
483
:uh, endophthalmitis on exam with
involvement of her, uh, vitreous and major
484
:risk factor being injection drug use.
485
:So Candida would probably be the
highest on my differential, but
486
:like they did in this case, you'd
kind of treat for everything until
487
:you know what you're treating.
488
:Sara Dong: Got it.
489
:So, she was started on systemic
high dose fluconazole on admission.
490
:Vitreous aspirate culture and blood
cultures were negative, and by day
491
:three, the vitritis had worsened.
492
:So, she ultimately undergoes a
vitrectomy, so surgical debridement of
493
:the vitreous, um, and those cultures grew
a fluconazole resistant Candida species.
494
:Any other thoughts on this case
and endophthalmitis in general?
495
:Akash Gupta: So, I think what's reflected
in terms of how they approach the initial
496
:empiric treatment is that the mainstay
of therapy, at least for the eyeball, is
497
:intravitreal injections of antimicrobials.
498
:And so this patient was given
that empirically by ophthalmology.
499
:And then when you think it's endogenous
and you think it's hematogenously
500
:spread, you also provide systemic
antimicrobials, although those probably
501
:do more for the systemic infection than
they do for the eye infection itself.
502
:They're just kind of supplementary
for the eye infection.
503
:We typically do use a long course of
antifungals if we do suspect candida and
504
:it's important to think about intraocular
penetration for your antimicrobials.
505
:So I mentioned that there's a sort of like
blood eye barrier formed at the retina.
506
:A lot of us have probably been in
this scenario where we suspect eye
507
:involvement, we have a patient empirically
on micafungin and then we're kind of
508
:trying to decide what to do because
micafungin and echinocandins penetrate
509
:the vitreous a lot less than azoles.
510
:And so I think in this case, azoles are a
very reasonable way to go and fluconazole
511
:was a reasonable empiric treatment.
512
:It was unfortunately resistant, although
it's unclear that if that's the reason
513
:that she actually failed the initial
attempt at management because she
514
:actually got voriconazole intraocularly.
515
:But sometimes even just despite getting
intravitreal antibiotics, even sometimes
516
:multiple times, and systemic therapy.
517
:Um, It fails and they ultimately do need
a vitrectomy for further management.
518
:And if the initial infection is
bad enough, sometimes we'll just
519
:jump to vitrectomy immediately.
520
:I guess I just have one additional
point where if you do have someone
521
:with injection drug use who's being
managed on methadone, it's just
522
:one thing to make sure that you're
monitoring QTC if you're going to use
523
:methadone and nasal at the same time.
524
:Miriam Barshak: That
was a great description.
525
:I mean, when you think about what a
fungal ball looks like, you can imagine
526
:it might be hard, even with intravitreal
treatment, to get good diffusion of the
527
:drug into the place where the problem is.
528
:It's just really a physics
problem more than anything else.
529
:The only other thing I wanted to add is
we get asked quite a bit about whether
530
:fungal markers are helpful from the
bloodstream and either making this
531
:diagnosis or following the treatment path.
532
:And I would say for people like this,
for whom their syndrome is probably
533
:related to transient fungemia and
not ongoing fungemia that usually
534
:those fungal markers are negative.
535
:So they're not, they're not useful
in ruling out the diagnosis and don't
536
:let that dissuade you from thinking
about endophthalmitis or otherwise.
537
:Sara Dong: Yeah, those
are great reminders.
538
:And just to pause and summarize again,
we just talked through endophthalmitis,
539
:which is that term describing infection
in the vitreous and or aqueous.
540
:And you guys talked a little bit about
exogenous versus endogenous as well.
541
:Alright, so I'm going to
move us forward to our next
542
:patient who's come into clinic.
543
:We have a 55 year old male, previously
healthy, who presents with five days
544
:of mild eye pain and progressively
blurry vision and floaters OS.
545
:The flashlight exam is normal,
but visual acuity OS is 20/200.
546
:The dilated fundoscopic exam
reveals retinal necrosis and
547
:vasculitis with associated vitritis.
548
:So he is diagnosed with
acute retinal necrosis.
549
:So we're going to hear a little bit
more about this mini case, but I'm
550
:going to stop us here to see if you
can talk about uveitis, and what
551
:infectious or non infectious causes
you're considering at this point.
552
:And I also think it's really easy for
people to get confused by alphabet soup
553
:and maybe need clarification on terms
like acute retinal necrosis versus
554
:progressive outer retinal necrosis.
555
:So can you help us out here?
556
:Miriam Barshak: Sure.
557
:When I think about uveitis, the first
and kind of most important distinction
558
:is which part of the uvea is involved.
559
:So as Akash mentioned, there's the
anterior uvea, the iris and the ciliary
560
:body, and then there's the posterior
uvea, which is the choroid that often
561
:is, uh, involves inflammation there,
often involves the retina as well
562
:and is associated with vitritis.
563
:The reason why that distinction
between anterior and posterior is
564
:important is because anterior uveitis
is most commonly non infectious.
565
:So usually these are autoimmune conditions
whether people have the ANA or the ANCA
566
:positive or whether they're sort of less
well defined autoimmune conditions, more
567
:than 90 percent of anterior uveitis is
non infectious, and we don't tend to get
568
:consulted so much for anterior uveitis.
569
:That being said, the subset that is
infectious is usually from HSV, and
570
:so often the ophthalmologists are
managing that on their own as well
571
:with topical or systemic therapies.
572
:Um, posterior uveitis is
kind of a different story.
573
:So usually posterior uveitis has
kind of a broader differential.
574
:Some of that is also noninfectious,
but worldwide, the most common
575
:cause of posterior uveitis is
actually toxoplasmosis and we
576
:refer to posterior uveitis.
577
:Again, the definition of that is the
choroid, but often there's involvement
578
:of the retina and the vitreous as well.
579
:But, um, there's anterior uveitis,
there's posterior uveitis, and then
580
:there's so called panuveitis, which means
essentially both the anterior and the
581
:posterior parts of the uvea are involved.
582
:In the U.
583
:S.,
584
:the most common cause of posterior uveitis
that we tend to see is herpes virus.
585
:Either HSV or VZV and that comes in
two flavors, as you were alluding to.
586
:So ARN, acute retinal necrosis, and
PORN, progressive outer retinal necrosis.
587
:I know someone once told me that, um,
it's hard to explain the difference, but
588
:you'll know PORN when you see it, haha.
589
:Um, to the ophthalmologist, there is
a distinct exam associated with PORN
590
:though, um, both of these entities
are associated with a vaso occlusive
591
:angiitis of the retinal vessels
that can, um, proceed to blindness.
592
:With PORN it tends to be much more
rapidly progressive because it
593
:involves the macula sooner and faster.
594
:And it tends to be in people who
are terribly immunocompromised.
595
:So people with advanced AIDS,
people who are on terribly high
596
:amounts of chemotherapy, and
they're really much more vulnerable.
597
:Um, so usually the distinction between
those two entities has to do with who
598
:the patient is and then what the exam
looks like by the ophthalmologist.
599
:These are both considered ophthalmologic
emergencies though, because even
600
:though HSV and VZV ARN are less rapidly
progressive than PORN, and they're
601
:both types of entities that can lead
to blindness that could be reversed.
602
:Sara Dong: Yeah, and so the second
half of this case, we learned that
603
:the vitreous aspirate was sent
for PCR testing for HSV and VZV.
604
:He receives an intravitreal injection
of foscarnet and has started
605
:on high dose oral valacyclovir
with close outpatient follow up.
606
:Two days later, the retinitis
has progressed and he ultimately
607
:requires admission for IV acyclovir.
608
:Vitreous PCR testing shows VZV.
609
:Miriam Barshak: Yeah, so, um, acute
retinal necrosis is most commonly
610
:caused by HSV VZV, and typically the
way the diagnosis is confirmed is with
611
:those intraocular samples, although
often it's a clinical exam by the
612
:ophthalmologist, and the treatment
should not wait for the confirmation of
613
:the diagnosis, because it's important
to start antiviral therapy early.
614
:Most of the time, um, systemic
antiviral therapy as well as intraocular
615
:antiviral therapy are used and the
usual intraocular treatment these days
616
:is foscarnet so it isn't necessarily
important to know which virus it is
617
:because that generally covers all of them.
618
:Importantly, acute retinal
necrosis usually impacts
619
:immunologically normal hosts.
620
:So while it's always worth thinking
about and looking for evidence of
621
:immune compromise and certainly
offering HIV testing and thinking
622
:about decreasing any immune suppressing
medicines that the patient might be on.
623
:Usually don't find anything as an obvious
cause, and so it isn't always clear why
624
:it is that someone has had this happen to
them, which is always a bit disconcerting.
625
:Typically the treatment that gets
started up front is oral valacyclovir
626
:and typically it's high dose and in a
normal kidney function patient, high
627
:dose means 2 grams Q8 hours and that's
almost the equivalent of what you
628
:can do with IV acyclovir, although IV
acyclovir with weight based dosing, you
629
:can probably get slightly higher levels,
so if people don't respond adequately
630
:to the oral within a couple of days,
the usual practice here is they'll get
631
:admitted for intravenous IV acyclovir and
then with the goal basically of halting
632
:the progression of their retinitis.
633
:And then typically because the
retinitis comes along with a lot of
634
:vitriol inflammation, 24 to 40 hours
into antivirals, um, systemic therapy
635
:with steroids is often started in
order to control that inflammation.
636
:The eye is a relatively unforgiving
place for having pressure built
637
:up from inflammatory response.
638
:And so often people have a
better chance of responding when
639
:steroids are started fairly early.
640
:In general, the course of treatment
is six weeks of antivirals.
641
:Once people have responded to that IV
therapy, usually the step down, uh,
642
:choices to go back on valacyclovir unless
there's reason to suspect resistant virus.
643
:Very occasionally, we've seen people
who didn't clinically respond to IV
644
:acyclovir and not necessarily for obvious
reasons, but there are a few case reports
645
:of patients who needed intravenous
foscarnet in order to be able to halt
646
:their disease, um, which is obviously
a much bigger deal in many ways.
647
:Akash Gupta: And I'll just add that,
um, my first patient that I admitted
648
:on my medicine clerkship as a third
year student had concurrent PORN
649
:syndrome and varicella vasculopathy
and I was like, wow, medicine is crazy.
650
:And then I later on realized that
that's become significantly more rare
651
:and that was the only case I've seen.
652
:Miriam Barshak: One last thing about
treating acute retinal necrosis is that
653
:because many of these patients don't have
an obvious reason for why this happened
654
:to them and because it's a vicious cycle.
655
:We often, um, de escalate to long
term suppressive antivirals in order
656
:to try to protect them from having a
recurrence either in the one eye that
657
:was impacted or perhaps in the other eye.
658
:This isn't always very well supported
by insurance, um, in the, in the long
659
:term with an explicit description of
the plan for long term antivirals.
660
:So sometimes it's a, it's a less
explicit plan for long term antivirals,
661
:but it's gonna be a long term.
662
:Sara Dong: Alright, so that was us
talking through a case of VZV retinitis.
663
:I'll move us to our next clinic
patient, who is a 25 year old
664
:male who presents a blurry vision
OD for the last several days.
665
:He has had a similar but less
severe episode about three
666
:years ago that self resolved.
667
:He is otherwise well and
is previously healthy.
668
:He immigrated to the U.
669
:S.
670
:from Brazil five years ago.
671
:And on eye exam, we see a creamy
white lesion adjacent to the scar.
672
:The view is hazy due to vitritis.
673
:And so I'm just going to jump to
the diagnosis and confirm that he is
674
:diagnosed with ocular toxoplasmosis.
675
:He's placed on trimethoprim
sulfamethoxazole, or Bactrim.
676
:So I was hoping you could share some
pearls about treating ocular toxo,
677
:and I would love to hear your opinion
in particular about how you think
678
:about risk benefits of secondary
prophylaxis for toxoplasmosis.
679
:Miriam Barshak: Absolutely.
680
:So ocular toxo, although it's not
something we necessarily see all that
681
:frequently here, um, and particularly
in otherwise immunologically normal
682
:people, just to to highlight that this
is often the only manifestation of toxo
683
:in people who are immunologically normal.
684
:It doesn't require that people have
HIV or low T cell counts or any
685
:other obvious immune deficiency.
686
:This is sort of a typical course of
ocular toxo for many people around the
687
:world and particularly in Brazil, where
they seem to have a more virulent strain
688
:of Toxo than what we tend to see here.
689
:These patients, as I mentioned, are
typically not immunocompromised, so, you
690
:know, looking for CNS toxo or doing an
extensive exhaustive workup for immune
691
:deficiency is usually not very rewarding.
692
:Um, but certainly it's worth considering
whether they may be immunocompromised.
693
:Don't be surprised if they're not.
694
:Usually the treatment in the old days
was pyrimethamine and sulfadiazine,
695
:but as those medicines have become more
difficult to access and more expensive,
696
:the TMP-SMX is really the new standard.
697
:In general, most of the data
about treating ocular toxo comes
698
:out of Brazil, where they have a
lot more experience than we do.
699
:Alternatives for people who can't
take trimethoprim sulfa include things
700
:like atovaquone or azithromycin,
although the amount of data for
701
:these treatments is much, much, much
less than the sulfa based therapies.
702
:Usually, for people that can't get
sulfa based therapies, the first option
703
:for a pretty severe disease actually
is intraocular clindamycin injections.
704
:Systemic clindamycin can also be used, but
there's not as much experience with that,
705
:and you can imagine the appeal of having
clindamycin given directly in the eye.
706
:As far as the secondary
prophylaxis, I think there's
707
:a couple ways to look at that.
708
:There's a group in Brazil that's
been looking at this question pretty
709
:intensely over the course of the last
few years, and the motivation for
710
:that is that most people who have an
episode of ocular toxo will relapse.
711
:More than half of them will if you
follow for a long enough period of time.
712
:So this group of Brazil most recently
put out their last randomized control
713
:trial, um, in 2020, where they looked
at people who were having an acute
714
:episode of toxo and they treated
the acute episode with trimethoprim
715
:sulfa for a defined period of time.
716
:And then they left people on
alternating day trimethoprim
717
:sulfa for a year following the
treatment of the acute episode.
718
:And they found that 28 percent of the
people in the placebo group versus 1.
719
:4 percent of the people in the TMP-SMX
group had a recurrence by six years,
720
:which is a pretty substantial difference.
721
:Again, they only treated people
for a year, but they followed
722
:them for five years thereafter.
723
:There will be, I'm sure, some update
subsequently about longer term follow
724
:up and whether a year is really
enough to change the longer term
725
:course of their, of their infection.
726
:But at this point, that's kind of
considered the standard approach
727
:is to put people on this, this
regimen that was studied for a year.
728
:Sara Dong: Great.
729
:So, moving from ocular toxo, we will meet
our next patient, who is a 35 year old
730
:with a history of sexually transmitted
infections, who presents with four days
731
:of ocular injection and blurry vision
in both eyes, without other symptoms.
732
:The eye exam shows panuviitis,
OD greater than OS.
733
:Lab testing returned with an RPR
of 1 to 256 and a positive FTA ABS.
734
:The patient is admitted for IV
penicillin and begins to improve.
735
:We, of course, know that syphilis
remains an issue and is going to play
736
:an increasing role in eye infections if
we continue to have increasing cases.
737
:So, can you give us a quick overview of
some of the major take homes that you
738
:think about related to ocular syphilis?
739
:Akash Gupta: You know, most, I think,
listeners, ID practitioners are very
740
:comfortable with syphilis because it's
been resurging, and so I won't get into
741
:like syphilis overall as a pathogen,
but, um, I think just one of the major
742
:take homes is, uh, that ocular syphilis
can be vision threatening, and so it's
743
:very important to think of in basically
every case of, um, syphilis, and I
744
:actually did recently have a, a case
where there was a very delayed diagnosis,
745
:um, mostly just because the patient,
um, hadn't presented to care for a
746
:long time, and, um, And she did have a
complete vision loss in one in one eye.
747
:So just a reminder that it
truly can be vision threatening.
748
:And then the other major take home point.
749
:And I try to emphasize this.
750
:I think I.
751
:D.
752
:docs are often familiar with this, but
I try to emphasize it with some of the
753
:PCPs and generalists that I work with
that it really can happen at any stage.
754
:It's most common in secondary
syphilis, but but it can happen in any.
755
:And so it should be kind of part of
the routine reflex algorithm checklist
756
:that you go through when you see a
case of syphilis is to ask about it,
757
:ocular, neurologic and otic symptoms.
758
:Basically no matter what stage
they're in, um, it can happen
759
:even with, uh, a negative RPR.
760
:And that could either be due to a truly
negative RPR, but with positive, um,
761
:treponemal testing, um, or it could be
due to the prozone effect where if you
762
:have a super high titer of RPR, um, it
can actually show up as a false negative.
763
:And so some labs will auto dilute
their samples to check for the prozone
764
:effect, but not every lab will.
765
:So it's helpful to kind of know
if your lab does and not use
766
:the absence of a positive RPR
to sway you in either direction.
767
:And then, uh, finally, and this is
a little bit newer in the last few
768
:years, um, is that the 2021 CDC
treatment guidelines no longer,
769
:uh, require an LP for CSF exam.
770
:That's not because they don't think
the CSF exam will be positive.
771
:It's, it's actually as positive in up
to 60 percent of patients who do have
772
:ocular syphilis, but the main reason being
that it probably won't change management
773
:in most cases and, um, it's treated
essentially similarly to neurosyphilis.
774
:And so, um, if a patient has isolated
ocular symptoms, no concurrent major
775
:concerns about neurologic involvement,
a LP is not, uh, as strictly necessary.
776
:Um, and then I'll let Miriam
add any additional comments.
777
:Miriam Barshak: Yeah, no, officially what
they say is, um, if there's no cranial
778
:neuropathy or other evidence of neurologic
involvement and there's a compatible eye
779
:exam, uh, and positive RPR that you can
assume that your treatment for ocular
780
:syphilis is appropriate and follow up
accordingly without the lumbar puncture.
781
:Sara Dong: Great.
782
:Yeah, I feel like this has been a
common topic and learning points
783
:that I've gone over because I've
had a lot of recent patients with
784
:questions related to syphilis.
785
:Alright, while we are closing in, we are
on our final clinic case for the day.
786
:A 65 year old woman is referred to ID
clinic after positive IGRA testing.
787
:She has uveitis that has been incompletely
responsive to variable doses of topical
788
:steroids over the past six months.
789
:There is some ongoing
conversation and consideration
790
:for systemic immunosuppression.
791
:For other background, she's received
the BCG vaccine as a child from a
792
:high TB burden country, but is not
aware of any known TB exposures.
793
:She immigrated to the U.
794
:S.
795
:12 years prior to presentation,
and she currently has no symptoms
796
:other than the blurry vision.
797
:Akash Gupta: So I can take
point on this one too.
798
:So these, um, honestly these were
the hardest cases that I saw with
799
:Miriam in clinic and continue to
be the hardest cases that I saw for
800
:ocular, um, symptoms in clinic when
I started practicing independently.
801
:And there's a couple of reasons.
802
:So, you know, Miriam mentioned that for
anterior uveitis, a lot of cases don't
803
:even necessarily get referred to I.
804
:D.
805
:because they are thought to
be autoimmune and some other
806
:causes found or no causes found.
807
:And they're sort of treated for
sort of autoimmune syndrome.
808
:N.
809
:O.
810
:S.
811
:Um, but, uh, you know, part of the the
workup they often do is to check for TB
812
:exposure and often will send an IGRA.
813
:And, um, that IGRA positive,
they'll often refer to I.
814
:D.
815
:to kind of discuss whether that
is indicative of this being,
816
:um, tuberculosis in etiology.
817
:And it's really, really hard to tell.
818
:So uveitis can occur in about 1.
819
:5 percent of patients with systemic TB.
820
:But it's extraordinarily
difficult to confirm.
821
:And unlike many of these other infections
we've talked about where ocular sampling
822
:can be super helpful, it's basically not
helpful in this case, and it's extremely
823
:unlikely to be positive, and so often
it's not even pursued or recommended.
824
:So in the absence of that, you
mostly kind of, uh, diagnose and
825
:treat presumptively, but, um, based
on extremely incomplete evidence.
826
:And so basically clinical approach
to this infection is primarily based
827
:on expert opinion at this point.
828
:And there is a lot of practice
variation, but there's been groups
829
:that have been trying to come to some
consensus, but that consensus is based
830
:on relatively minimal information that
we have in the, in the literature.
831
:So there are certain features that are
thought to maybe be more consistent.
832
:So one is certain findings on eye
exam, um, and those particularly
833
:involve involvement of the choroid.
834
:So that's that sort of posterior uvea
layer, and there can be specific patterns
835
:that they might mention on exam, like
serpiginous, like choroiditis, um,
836
:a choroid tuberculoma or tubercles,
although those can sometimes look
837
:like other etiologies as well.
838
:And then multifocal choroiditis.
839
:Other features include recurrent episodes.
840
:And so, you know, if they, if they give
treatment for some other etiology and
841
:either it works, uh, incompletely or
it, it recurs, that can suggest maybe
842
:this truly is due to untreated TB.
843
:One important lesson, and that comes
up in this case, is that a response
844
:to steroids does not rule out TB.
845
:So the nature of a sort of TB uveitis,
uh, is that it will respond to steroids
846
:in some way, but probably incompletely
and, and without like a long duration.
847
:And, and so you might get that recurrence,
but, um, sometimes people will think
848
:like, okay, well, if this truly was
an infection, that wouldn't have
849
:helped, but that that's not true here.
850
:And so it can't necessarily be used.
851
:So, uh, while evidence of concurrent
active or systemic TB can be supportive,
852
:um, many, or most patients probably
won't have other evidence of active TB.
853
:And so in practical application, you know,
we look for it and usually don't find it
854
:and then still have to decide what to do.
855
:So sometimes, and this is kind
of what we did a lot of the time,
856
:is you decide if there's enough
there for you to try therapy and
857
:basically see how they respond.
858
:And so that would be sort of observing a
clinical response over weeks to months.
859
:And empiric treatment is similar to
other forms of TB and may include
860
:RIPE, but sometimes we'll avoid
ethambutol and replace it with
861
:moxifloxacin instead, because we're
trying to avoid further eye toxicity.
862
:And then you can actually get paradoxical
worsening after starting TB therapy,
863
:and that can be treated with steroids.
864
:And sometimes it actually makes you
feel a little bit better about your
865
:decision to treat, because if, uh,
you know, maybe the TB therapy is
866
:actually working and causing die off
of organisms and, and, um, confirming
867
:the diagnosis, but it is really tricky.
868
:And, you know, sometimes you go months
into a treatment course, and then, uh,
869
:ultimately, you say, I guess, you know.
870
:If it didn't work, you're either stuck
deciding whether this is a resistant
871
:TB or whether it just wasn't TB at all.
872
:And so, um, it is a, it's a challenging
area of communication with patients,
873
:primarily just because there's so
much uncertainty and, um, and you
874
:just need to get very comfortable
with that uncertainty together and,
875
:and decide on a management plan.
876
:I'll let Miriam add anything.
877
:Miriam Barshak: Yeah, that was a great
summary of what our lives are like
878
:in trying to, um, yeah, deciding what
the right thing is to do for patients.
879
:I think it helps if the patient has
a good understanding about the idea
880
:that the treatment is diagnosis,
essentially trying to diagnose
881
:based on the response to treatment.
882
:Um, usually even if it's clear that
there's no clinical response to the
883
:treatment, we try to finish out the
duration of latent TB treatment with
884
:the TB meds so they've kind of cleared
the air and that they can again, get
885
:whatever immunosuppressive treatments
are felt to be more appropriate for
886
:what's more likely an autoimmune
condition cause of their uveitis.
887
:Sara Dong: Well, thank you
guys so much for taking us
888
:through this long clinic day.
889
:This was quite the tour de
force of ocular infections.
890
:So I really hope that people take
a listen, read the paper, and
891
:start to feel more comfortable
in approaching these cases.
892
:And I really love your emphasis
on really partnering and
893
:communicating with your ophthalmology
colleagues and your patients.
894
:So before we wrap up, I will open the
floor just to see if you have any other
895
:final closing thoughts or comments.
896
:Miriam Barshak: So I wanted to
take the opportunity to thank
897
:our dream team of authors.
898
:I feel like that was actually one
of the most satisfying parts of
899
:the whole project, was to be able
to get with, to get to work with
900
:and write with such amazing people.
901
:Dr.
902
:Dolman, who's a, um, corneal specialist.
903
:Dr.
904
:Papaliotis, who's trained in both
ophthalmology and medicine, um,
905
:and Akash andAmir, um, and Dr.
906
:Marlene Durand, who was my mentor and
has been at Mass Eye and Ear for over
907
:20 years, and probably taught most of
us, that we know about eye infections.
908
:Akash Gupta: Um, yeah, I
totally agree with that.
909
:It was really fun and, you know, we
all took point on different sections
910
:and it was actually really fun to
read other people's sections, um,
911
:because I invariably just reading them,
I, I learned things I didn't know.
912
:Um, and so it was just
fun to have that group.
913
:Sara Dong: Thank you to Miriam
and Akash for joining us today.
914
:If you want to check out their
article, make sure to look at Clinical
915
:Infectious Disease or CID State of
the Art Review Ocular Infection.
916
:So this will be linked in the
consult notes as well as in
917
:the episode info description.
918
:Don't forget to check out
our website, febrawlpodcast.
919
:com, where you will find the consult
notes, which are written supplements of
920
:the episodes with links to references.
921
:Our library of ID infographics
and a link to our merch store.
922
:Febraw is produced with the
support of the Infectious Diseases
923
:Society of America or IDSA.
924
:Please reach out if you have any
suggestions for future shows or want
925
:to be more involved with Febraw.
926
:Thanks for listening.
927
:Stay safe.
928
:And I'll see you next time.