UA-184069179-1 116: StAR: Ocular Infections - Febrile
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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
Sara Dong:

Hi, everyone.

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Welcome to Febrile, a cultured podcast

about all things infectious disease.

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We use consult questions to dive into

ID clinical reasoning, diagnostics,

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and antimicrobial management.

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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.

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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.

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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

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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.

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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.

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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

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the anterior chamber, the space

between the cornea and the iris.

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Um, the AC is the designation

for the anterior chamber.

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And again, that's between

the cornea and the iris.

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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.

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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

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that's given to the, um, removal

of the vitreous, which is something

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that's done sometimes for diagnostic

and sometimes for therapeutic reasons.

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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

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of the retina are more important for

low light and peripheral vision, and

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that is important because infection

involving different areas of the retina

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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

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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.

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B stands for brightness,

little counterintuitively.

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Um, but that's an ultrasound, so it's

basically an ultrasound of the eye.

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And on a B scan you can see inflammation

in the vitreous or areas they may

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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

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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,

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which is a different kind of angiography

that looks at the cord and retinal

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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

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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

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I'm not misinterpreting information.

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Um, so now everyone has a resource

in Table 1 that summarizes all these

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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

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I used to help prep for clinic,

and it's called, um, eyeguru.org

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and simply eyeguru.org/translater,

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and it's literally an

ophtho note translator.

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Um, so you can put in, like, terms

or strings of terms or phrases

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that you see in an ophtho exam or

something, and it will turn it into,

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like, understandable prose for you.

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Um, so I, that is

something I've used a lot.

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I don't know if, you know, as AI

develops, that will become less

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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.

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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,

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redness, pain, and visual changes.

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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

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slit lamp exam shows corneal

edema with pseudodendritic

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lesions and fluorescein staining.

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So what are we dealing with here?

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Miriam Barshak: Right, so whenever

we hear about redness of the eye, um,

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many non specialists initially think

of conjunctivitis because that is

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certainly the most common infectious

cause of redness of the eye, but

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conjunctivitis doesn't usually come

along with pain and definitely doesn't

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come along with visual changes.

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Those are things that make you

need to think about something else.

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And especially knowing that there's

a vesicular rash on the forehead.

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That's kind of the, um, the strong

suggestion that there may be a viral

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process going on, probably zoster,

dermatomal zoster, which in the V1

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distribution has an associated risk of

involving various structures of the eye.

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Classically with that, um, we advise that

patients should get an eye exam, even

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if they don't have ocular symptoms, but

if they do have ocular symptoms, then

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they should have a very prompt eye exam.

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The treatment of ocular involvement

with herpes zoster requires more

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than just systemic antiviral therapy.

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So the most common, um, eye involvement

that does get seen in these types

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of patients is some combination

of conjunctivitis and keratitis.

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And when you put this together,

you get keratoconjunctivitis.

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Just in, in general, when we think

about conjunctivitis, there are other

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much more common viral causes of

conjunctivitis, the most common one

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being adenovirus, and conjunctivitis in

adults in general is most commonly viral.

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So adeno is often at the top of

the list, not in this case, but in

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most otherwise healthy patients.

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Again, that's not usually

vision threatening.

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And diagnostically, it's

often a clinical diagnosis.

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Think about watery drainage, but really

that doesn't necessarily have the

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greatest sensitivity or specificity

and in better careful studies, there

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are other factors that can help you be

more confident about that diagnosis.

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Things like having a lot of itching,

having having contacts with other

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people or having other viral symptoms

that may go along with having an

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adenovirus syndrome, having a runny

nose or other sorts of, um, of symptoms.

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Bacterial infections in adults of the

conjunctiva are relatively uncommon, um,

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but in children, bacterial infections

of the conjunctiva are much more

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common than the most common bacteria.

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Bacteria wise conjunctivitis include

pneumococcus, staph aureus, and H.

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flu in adults.

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As I mentioned, bacteria are much less

common, but of course, the only way

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to get a clear diagnosis of what it

is that you're treating as a bacterial

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infection would be to get a culture.

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Keratitis, in general, is more commonly

caused by bacteria than by viruses.

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So our case is a viral infection, but to

put that aside for a moment, most of the

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cases of keratitis you're likely to come

across are bacterial and the primary risk

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factor for keratitis is contact lens use.

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And when I say contact lens use,

what I really mean is lapses in

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hygiene associated with contact

lenses, which are really common.

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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.

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