dr trevor gray - gp cme north/sat_room2_1630_gray...six/six eyes with detectable adenovirus by qpcr,...
TRANSCRIPT
Dr Trevor GrayClinical Senior Lecturer
Ophthalmology
University of Auckland
Auckland
16:30 - 17:25 WS #160: Case Studies in Ophthlamology
17:35 - 18:30 WS #172: Case Studies in Ophthlamology (Repeated)
What sort??1. Pharyngo-conjunctival fever (PCF)
2. Epidemic kerato-conjunctivitis (EKC)
3. Acute non-specific follicular conj’
4. Chronic keratoconjunctivitis
Pharyngitis
Follicular conjunctivitis
Fever
Mild epitheliopathy 30%
Infiltrates rare
Lymphadenopathy
Clinical features and treatment of
adenovirus infections. Rev Med Virol.
2008 Nov-Dec;18(6):357-74.
Hyperacute
Adults > children
Flu-like illness in <50%
80% severe keratitis
Usually adenoviral types 8 & 19
Haemorrhagic conjunctivitis
Lenaerts L, et al. Clinical features and treatment of adenovirus infections. Rev Med Virol. 2008 Nov-Dec;18(6):357-74.
Sub-epithelial infiltrates
Vision threatening
Early as 2 wks - 6 mths
43% of EKC
Lymphocytic infiltrates
Management
Prevent transmission!
Practice protocols …2% hypochlorite or Betadine
Patient instructionsSupportive, may get worse before resolving
12d viral shedding
Up to 2 weeks off work
Role for diagnostic test?
DiagnosisUsually clinical
Health professionals – test?
RPS Adeno-Detector $20+GST
Rapid immunochromatographic test for adenoviral antigens (hexon protein)
10 min
Adenoviral PCR also available for health professionals
Viral culture can take 2 weeks
Lubricants?
Vasoconstrictors?
… NO effect upon course or infectivity…
12d viral shedding
Up to 2 weeks off work…
Risk of sight-threatening SEI
We can do better … ☺
Pseudomembrane
“Exposure to PVI at a concentration of 1:10 (0.8 %) completely extinguishes infectivity of free adenovirus
PVI is less effective against intracellular adenovirus
Healthy epithelial cells can be exposed to PVI for up to 6 hours without cytotoxic effect”
“PVI was effective against all the virus species (adeno, mumps, rota-, polio-, coxsackie-, rhino-, HSV, rubella, measles, influenza and HIV) tested
PVI inactivated all the viruses within a short period of time”
Povidone-iodine for treatment of adenoviral conjunctivitis: an in vitro
study Klin Monbl Augenheilkd. 2006 May;223(5):349-52.
Inactivation of human viruses by povidone-iodine in comparison with
other antiseptics. Dermatology. 1997;195 Suppl 2:29-35.
“combination povidone-iodine 0.4% & dexamethasone 0.1% sterile ophthalmic suspension given four times daily for a minimum of 5 days
eight/nine eyes enrolled in the study, clinical resolution was observed by day 3 or day 4
six/six eyes with detectable adenovirus by qPCR, significant reduction in viral titre was seen by day 3, day 4, or day 5
elimination of infectivity was achieved by day 4 or day 5”
A combination povidone-iodine 0.4% & dexamethasone 0.1%
ophthalmic suspension in the treatment of adenoviral
conjunctivitis. Adv Ther. 2009 Aug;26(8):776-83.
dexamethasone 0.1% or hypromellose 0.3% drops four times daily for 1 week
111 patients were randomised
significant symptom difference between treatments p=0.0248
No patient experienced a serious complication
All topical steroids have been shown to enhance viral replication and increase duration of viral shedding
NSAIDs do not have same effects
….. No shortening of infectivity and time off!
A randomised placebo-controlled trial of topical steroid in
presumed viral conjunctivitis. Br J Ophthalmol. 2011 Sep
Our Formula:0.05ml of 5% (Ophthalmic Strength) Povidone-Iodine to a single Minim of Pred Sodium Phosphate 0.5%.
Since the volume on a Minim is 0.5ml, this is a 1:11 dilution of the Iodine, so you end up with 0.45% Iodine and basically still almost 0.5% Pred Sodium.
Our Formula:We give the patient 3 Minims with instructions to use in the affected eye TID for 3-4 days.
Cost: about $12 for 3 Minims of Pred Sodium, syringe 50 cents, needle 17 cents, Iodine ? not much. We usually charge Px $19 to cover costs, plus consult fee.
Optimus Healthcare Compounding Pharmacy – Penrose AlkPrednisolone Sodium 0.5% with 0.5% P-I: 1x5ml $39Dexamethasone 0.1% with 0.5% P-I: 1x8ml $57
Mx of Adenoviral KC – treat: povidone iodine & steroidOffer to all
0.5% povidone iodine & 0.5% prednisolone
Halves viral shedding time
Clinical resolution by day 4
reduction in viral titre by day 3-5
Happy patient & Dr
Optimus Compounding Pharmacy 09 580 0915
A combination povidone-iodine 0.4%/dexamethasone 0.1% ophthalmic suspension in the treatment of adenoviral conjunctivitis. Adv Ther. 2009 Aug;26(8):776-83.
CPAC scoreHigh variability in CPAC Score between DHBs to be eligible for public funding of cataract surgery
45 – ADHB
48 – WDHB
53 - CMDHB
53yr music teacher Wanganui Collegiate, mother, sole earner
Husband heart attack
Son chronic kidney disease
Bilat early onset cataracts (PSCC)R=6/18 L=6/9-2
Glare R=6/24 L=6/18
Unable to mark student papers
Driving dangerous
About to lose drivers license…
DHB denied access to publically funded cataract surgery
Mrs E 69yrs
Husband with Alzheimer's, lost his driving license.
Mrs E sole driver. They lived rural so a car was essential.
Patient told would not pass eyesight test for next driver license test.
Told by public hospital that there were patients with greater need.
GP did not know about ARCH. Optometrist did.
Bilat cataracts through ARCH.
A need?
Skills & facility?
Motivation?
How to make bigger than one?
Could 3rd party do all the admin’? Minimal hassle for surgeons
Deliver patients to cataract surgeons throughout NZ?
Would surgeons give 20min per month?
“Auckland Regional Charity Hospital”
Since 2009
Drs Luigi & Fiona Sussman
Canterbury Charity Hospital2018 Community of the Year award
Virtual…
Charity...
‘Hospital’...
28 surgeons & anaesth’
400 referrals, 270 surgeries
cataracts, pilonidal sinuses, haemorrhoids, Hernias, cholecystectomy, breast reduction, varicose veins arthroscopic hip surgery, lumps and bumps, ingrown toenails amongst others
Your patient denied public surgery (cataract, other…)
Significant compassionate reasons for surgery
Patient cannot afford private (as best guess by GP and/or Optom’. No Insurance, no ACC)
Referral to ARCH (website)
Patient found eligible for pro-bono cataract surgery
Volunteer surgeon offers 15-20min of his/her time to do surgery
Volunteer surgeon is notified that there is an eligible patient in their region
Auckland initially to iron out glitches
Surgeon & anaesthetist pro-bono, nurses paid, theatre costs covered
We welcome your referrals! ☺
