January 29, 2025 • 31 mins
Acanthamoeba keratitis can be one of the most devastating diagnoses in ophthalmology, as it can wreak havoc on the cornea unlike few other microbes. On the same token, if caught early, acanthamoeba can be treated quite efficiently and effectively, and patients can have minimal, if any, long-term visual sequelae. Given acanthamoeba is such a dreaded diagnosis, just the thought of it can invoke fear into the ophthalmologist. And while many of us might have a basic approach to acanthamoeba, we also surely have blind spots in our diagnosis and management of this condition, as evidenced by many patients being diagnosed weeks after it occurs. Dr. Chris Rapuano joins the podcast to discuss this important condition.
This episode is sponsored by Thea Pharma Canada - https://www.theapharma.ca
Become a supporter of this podcast: https://www.spreaker.com/podcast/blind-spot-the-eye-doctor-s-podcast--5819306/support.
This episode is sponsored by Thea Pharma Canada - https://www.theapharma.ca
Become a supporter of this podcast: https://www.spreaker.com/podcast/blind-spot-the-eye-doctor-s-podcast--5819306/support.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:12):
Hey everybody, I'm zaeo Mednik and welcome to another episode
of blind Spot. This episode is sponsored by THEO Pharma Canada.
THEA pharm of Canada is the Canadian subsidiary of THEA,
Europe's leading pioneering and innovative eye health brand. Founded in
nineteen ninety four by Henri Schibre. With five generations of history,
the Chubret family has been dedicated to I care for
(00:32):
more than one hundred and fifty years. Their commitment to
improving lives is born of their pioneering spirit. They continue
to lead the worldwide preservative free movement in eye care.
They've created innovative delivery systems. They've focused on making products
accessible and cost effective for patients. They live this mission
every day because everyone should have the same opportunities to
see the world through healthy eyes. So thank you THEO
(00:55):
Pharmer Canada for supporting blind Spot. A cant Amba cara
titis can be one of the most devastating diagnoses in ophthalmology,
as it can wreak havoc on the cornea unlike few
other microbes on the same token. If caught early, A
canthony that can be treated quite efficiently and effectively, and
patients cannot have minimal, if any, long term visual sequelle.
In some cases, given a cantemiba is such a dread diagnosis,
(01:18):
just the thought of it can invoke fear into the optalmologist.
And while many of us might have a basic approach
to acanthemiba, we also surely have blind spots in our
diagnosis and management of this condition, as evidenced by many
patients being diagnosed weeks after it occurs. I'm joined today
by Chris Rapuano. Doctor Rapuano is a nationally an internationally
recognized expert in cornial diseases, is chief of the Will's
(01:40):
I Cornea Service and a professor of ophthalmology. He's authored
several books, including the Will's I Manual, which is known
by Everybody and I Care, and he was recently offered
on The Ophthalmologist Powerless of twenty twenty four, recognizing him
as one of the top one hundred most influential ophalmologists
in the world. Doctor Rappoano joined us previously on our
episode of the podcast discussed recurrent corneel erosion syndrome, and
(02:02):
today he joins us again to discuss a can't amba
all right, So doctor Chris Rapuano, welcome back to the podcast.
Second time. Very very exciting, more so for me than
for you, but very exciting.
Speaker 2 (02:12):
Oh thanks, sale happy to be here.
Speaker 1 (02:14):
So we were chatting about doing a second episode and
we were throwing a few ideas around and you suggested
a cantamba. I said, maybe that's a little too big,
which may have reflected the fact that a cant amba,
even as a cornea special stresses me out a little
bit because there's so much about it. And he said, no, no, no,
I think we should do a cantamva. It's an important
topic and I could not argue with the importance of
(02:36):
the topic, and definitely something that fits into this theme
of blind spot where a lot of us know you
don't want to miss a cantamba, but clearly there's a
blind spot reflected in the fact that diagnosis is often
so delayed. So let's talk first. I guess about why
you felt this was such an important topic to do.
Speaker 2 (02:55):
Well, A can't tomba, as we all know, is a
rare condition, and rare conditions are things that we kind
of keep out of our mind and really just don't
think about. And that's the problem with a canton meba
some some patients that we see. We see lots of
patients of corneill ulcers, but if you don't think about
a diagnosis, you won't make the diagnosis. And I'm on
(03:19):
the board of OMIC, the Atomic Richard Insurance Company, which
ensures about half the ophthalmologists or who go who go
for private I'm not practice shurans in the United States,
and we have seen several cases recently in the past
year or two of misdiagnosed slash undiagnosed a canton meba.
(03:40):
Like otherwise good doctors, sometimes corneus specialists who just don't
think about the diagnosis and and eyes have really gone
down the tubes. So you know, it's something that we
I think about all the time. Just as a tertiary
care hospital, teaching hospital. You know, I'm running through the
different ends with the residents and the fellow so it's
(04:02):
part of that. But it is missed not infrequently, and
the sequeli are potentially devastating if if you missed a
diagnosis for too long. But that's why I think it's
an important thing to talk about.
Speaker 1 (04:17):
So, as you said, there can't Amba is notorious for
having a delayed diagnosis. Often people are shuffled around to
multiple ie care specialists. Maybe treated for simplex because you
can have that dendrotic appearance. Maybe treated for a bacterial
care titis because it can have that appearance too. And
what are some of your tips for off the bat
(04:38):
thinking this is a cant amba so you don't wait
for that right because obviously you want a culture and
you want to do you want to take swabs and
for culture PCR and we'll talk about that, but still
there can be a delay for that to even come back.
So some of your tips so people don't run into
this problem, aside from just maybe one thing which is
(05:00):
important being more aware and conscious of it.
Speaker 2 (05:04):
My biggest tip is if we have a soft contact
lens where who comes in with a diagnosis of herpes
simplex carotitis to me, sure they can have herpe simplex
just like anybody can. But you have to think about
a cant a eva. That is has to be in
your differential and you can say, thought about cantinba, it's
(05:27):
a classic dendrot it's not Acanthinba. Doesn't go along with
and you're done, And that's fine if you don't think
about the diagnosis of a cantin eva in that particular case,
then you may miss it. And that's what's happened in
numerous of these malpractice cases that I've reviewed, is they
were either diagnosed by the doctor who's being sued, but
(05:48):
more commonly they're diagnosed by the referring doctor. Oh, this
patient has had herpes for a few weeks, not getting better.
I'm sending them to you, and then you get the diagnosis, Oh,
they have herpes there for I'm not thinking about anything else,
and that doesn't work. I mean, it doesn't work when
it's a caan't the meba. And why were they originally
(06:10):
diagnosed with herpes? In these cases, they probably did not
have herpes, but they probably had a pseudodendritic epitheliopathy, So
a funny looking kind of dendritic pattern in the cornea
that you can see with relatively early acant the MEBA.
And if you diagnose herpes and go down that pathway,
(06:30):
then you're delaying your diagnosis of a can't and meba.
So these are soft gutting lens wearers, and they often
have a history of it a few days, even a
couple of weeks of symptoms. They may have severe pain,
but these patients did not have severe pain. None of
them had severe pain that you kind of at least
early on that you kind of think, oh my god,
(06:51):
could this be a cant the meba. And when they're
not severe pain, you may think of herpes as I mean,
the nerves are so healthy, they're neutrophic. That is the
other thing I would. I would The other kind of
clue is you do not have to have severe pain
to have the diagnosis of ACAMT the meva. Yes, that's classic,
and if you have the severe pain, you may make
the diagnosis earlier, but you don't have to have it.
(07:13):
You still have to think of a camp and meba
very succinct.
Speaker 1 (07:17):
A very good point there about contact lens where who's
diagnosed with AHSV And it's really tempting in all of medicine,
and I mean for ophalmologists and optometrists too. Or listen
to this when you're given referral note which has a
diagnosis on it, because it's natural. It's natural to think, oh,
this is what it is, Okay, how can I better
treat this? They're sending this to me because I'm a
(07:37):
corny specialist. What else do I have up my sleeve
to treat HSV? But it's not HSV? What are some
of the other classic things on history here? I'm thinking
swimming lakes, contact lenses. What are some other features that
we should be asking about. It's kind of two questions,
and do we understand how a can't the meva actually
(07:58):
develops in these situations?
Speaker 2 (08:01):
Well, so the first part is kind of predisposing factors
soft counting lenswares by far the top predisposing factor, and
just saw cod answer alone with nothing else. But you know,
swimming pools, lakes, ocean, a hot tub, you know, probably
even higher on the list. And then the other one
is trauma, trauma with any trauma or trauma with getting
(08:24):
something kind of in the eye. We know that acanthy
be was ubiquitous. It lives everywhere. You can culture it
all over the place. But then question is, well, if
it's all over the place and everywhere, why do some
people get it? I personally don't have a great reason.
I suspect that the contact lenses have caused some microabrasions
of the cornea and that just allows the acantho be
(08:45):
able to get in you know, why do most people
have it in one eye and not both eyes? Although
I have seen patients, even my most recent patient had
it very mild in one eye and severe in the
other eye, so you can get in both eyes. So
I don't know. I don't think we exactly exactly why
that happens. The other thing is if a patient's being
(09:05):
referred in for herpe simplex then and they've been under
good treatment for herpe simplex, then you have to think
why is the herpe simplex not getting better if they're
being treated well. Or if I'm set to patient with herpes,
I treat them for herpes and I see him back
a week later, I'm and I'm giving them kind of
(09:25):
a full court press treatment for herpes, and it's not
getting better, even if I didn't think of a canthemya
the first day I saw them. If herpes treatment is
not getting better, then you need to think about akatama.
And the problem was in these cases that I mentioned,
they saw them numerous visits and never thought about ach.
Speaker 1 (09:48):
Is there always something to scrape? And what I mean
by that is sometimes sometimes somebody might not have an
epithelial component to that of cantemba perhaps or maybe that's
maybe that's not the case, and then you're wondering, hmm,
this looks strange, but I don't want to create an
epithelial defect to swab. And sometimes I have that debate
in general with correctly going away, what's your thought process
(10:11):
on that? And I mean, how important really is that
swab and that diagnosis on PCR typically for moving forward.
Speaker 2 (10:20):
Yeah, So there are lots of different ways to try
and make the diagnosis of a cant To MEBA, obviously
you've got the history and the exam, but at WILLS
we will typically do an epithel scraping and two different
scrapings sheets of epithem and send it to our pathologists
around the Eagle and Tatanamilman, and they're excellent at finding
just searching, searching and finding acanthemi the cists. Other You
(10:42):
could also send a scraping for cultures, you know, an
you call it overlay culture. You can send it for PCR,
which which can take time, and then you can use confocal,
which my cross could be, which I don't have at WILLS.
But those are other ways to make the diagnosis. Sometimes,
as you suggested early acantemba tends to be in the
(11:03):
epithelia you see epitheliopathy. That's the ideal time to make
the diagnosis because it's in the epithelium and it'll show
up much more easily on culture and on studies. The
problem comes up when it later several weeks after the
acanthomba started. We think that the acanthemba organisms and sys
(11:25):
kind of leave the epithelium and go into the stroma
and are now if you scrape the epithelium, epithelium is now
pretty normal or doesn't have the the acafeu bid in,
but it is in the stroma. So at that point
we don't necessarily have a confirmed diagnosis of acantemba. And
what do we do? So to answer first question, I
(11:47):
will do a scraping anyway, because if I can show
I will create an epithel defect. Certainly, if there's any
epitheliopathy that looks like maybe acantemiba, I have no problem
creating a big epithelial defect. And in acantomba typically that
heals pretty well as opposed to bacterial ulcers which may
not heal quite as well. Et cetera. But I have
no problem doing that. To make the diagnosis. Once it's
(12:10):
in the stroma, it's harder to make that diagnosis. And
I will treat empirically. Based on my suspicion. I think,
oh my goodness, it's the history the exam goes with acantamiba.
I'll do my scraping today. I'll even start my treatment
even before I get an answer from the scraping. I
love a confirmation because the medications are toxic and they
(12:33):
go for a long, long time, and I really want
to be sure I've got the correct diagnosis subjecting the
patients to this. But I'm unable to get that, but
I'm really suspicious of it. I will still treat them.
Speaker 1 (12:44):
And that was my next question. Sometimes there's this debate.
You obviously want to have the diagnosis with PCR culture,
especially because this is going to be long treatment typically,
so you write long and toxic and painful, so you're
going to commit them to that. I know it's important
to treat it right away, but sometimes there is that
debate in somebody. Let's say they do have an epithelial defect,
(13:06):
they do have a pseudodendrite, and you send it and
it's going to be a few days before you get
it back. I guess what is your threshold when you'll say,
you know what, we can wait a few more days
until we get this. We can get this back to
make sure we're treating the right thing before these toxic,
expensive medications, or we should we should start right away.
And I as I asked that, I realized that with
(13:28):
many things, the answer is the answer is it depends.
And I'm guessing. I'm guessing to go back to what
you said. If you had a contact lens where who's
been diagnosed with HSB, who's been on Valley cycle he
or a cycler has been on gan CYCLVI or JEL,
it's been on everything and they're in a ton of pain,
or there's no history of HSV. In that situation, you
might just say, okay, let's let's scrape, but start right away.
Speaker 2 (13:52):
Yeah, you're absolutely right. It depends, and it depends on
my clinical suspicion. How should in the mind they do
have a canton eva just by you know, the history
and the symptoms and the clinical appearance. And if I'm
maybe maybe not, then I don't think there's necessarily terrible
(14:15):
harm in waiting a few days till I get you know,
a path diagnosis or culture or PCR diagnosis. If I
am pretty certain it's a canton meba, I will start
them that day and then I'll send things for a
and I'll send things for you know, bacteria, fungus too.
And then obviously if it comes back some weird fungal
(14:37):
ulcer that I wasn't suspecting, I say, uh, parked up
the wrong tree stop by a anthoniameds. And now treat
my fungal diagnosis. That can happen on rare occasion where
you just send for things and an unsuspecting thing shows up,
you've got to change your plan. But if I'm pretty
sopeicificate canton eba, I will treat that.
Speaker 1 (14:58):
For the actual swave. When you're getting a sample, you
mentioned you want a sheet of epithelium, and I've heard
that before. That kind of in contrast to when I'm
doing a bacterial culture, where I I'm kind of just
going at the the infiltrate that's obviously there. Right, I
am more cognizant in a camp of me, but to
(15:19):
make sure I get some actually a sheet of epithelium,
like you said, surrounding epithelium that's supposed to be higher yield.
Is that correct?
Speaker 2 (15:28):
Yeah? Correct, especially for us at Will's. We're setting it
for a pathology. We're taking that sheet and we're laying
it down ideally as a sheet on you know, the
glass micro slide, and then then we said that we
walk it right up to pathology. Actually, nowadays they've given
us the actual fixative to actually fix it in the
Cordia office and then bring it upstairs to micro and
(15:50):
then they'll read it within twenty four hours. So we
get a pretty rapid turnaround on that. And sometimes I'm
sure it's a caret and meba and and the the
epithelium is negative for it can't amba, and then I'll
keep treating until I decide not to.
Speaker 1 (16:09):
So if you get a positive, obviously you know it's
a can't amba. If you get that doesn't necessarily preclude
the diagnosis.
Speaker 2 (16:15):
Correct, that's correct. And again it'll go by my suspicion.
If I'm very suspicious, I'll keep treating, so so then
I might stop or if I sometimes patients are sent
in for a rule at a can't amba, and I'll say,
I don't think that's what it is, but I'm really
not one hundred percent sure I will send that up,
(16:36):
not treat them and wait for wait for UH pods
of diagnosis to start treating Chris.
Speaker 1 (16:42):
I think for me, what's most daunting about a can't amiba.
And I am a cornea specialist, but my naivete is
on full exposure on this podcast, is that there's just
so many options for treatment. So for me, it's not
I mean, the diagnosis is obviously something I don't want
to miss and I'm concerned about it, but it's often
that when I do decide, okay, this might be a
(17:03):
canth amba, I've got charts on my phone, I go
to the Wills Manual, which you which you created. There's
so many options, right, there's chlorhexadine, there's PHMB, there's topical iconasole,
there's oral vericonisole. And when there's so many things which
work differently in their mechanisms in how they target a
(17:24):
cante me, but it can be a little bit daunting.
I think to people in what the approach is? What
is your treatment approach to a cant am memba.
Speaker 2 (17:34):
Yeah, it is. It is a big issue because there
are lots of different treatments out there, and you talk
to different specialists all over the country or the world
for that matter, and they each have their own kind
of regimen that they use.
Speaker 1 (17:44):
So we're gonna go We're gonna go with the rappawano
regimen here.
Speaker 2 (17:47):
Yeah, there's there's there's no right or wrong to this.
But what I've done in the past is I use PHMB.
Our pharmacy will make that up. We've used the point
oh two percent PHMB, which is probably hex methylene bikewanide,
which is the baquasil kind of pool cleaner that that's
in a diluted form, and we'll start that every hour
(18:07):
around the clock. In general, what I've done in the
past and what I still do actually my current treatment
is I will also use broline for parmudine drops, which
are not available in the US, but I will get
it from an internet pharmacy and then basically give it
to the patient. And that's also every hour around the clock.
And that'll be for usually again depending on the severity
(18:31):
and how they tolerate it, for the first week or
two or three, but usually maybe the first week, and
then I'll cut down the nighttime meds W two and
then cut those again. So I stopped the nighttime meds
to get patients from sleep and then see how they're doing,
and then slowly cut down those two other medications. If
it's really bad, I will also use noltefazine pills. These
(18:53):
are pills that are kind of fully FDA approved for
kind of protozo in the brain, but have some type
of compascit use approval for a kantemybic caratitis. So maltepazine
is a pill that's I think it's fifty milligrams. It's
I think it's tight today, two or three times a day,
(19:14):
and it's for a one month course is what I'll
typically give it for. You need to check their liver
function test or couldney function test, and I get a
CBC two before I start it, just to make sure,
and they'll check it every few weeks that they're on
the medication, or have their interness check that. It's a
pretty strong medication, but it can work well. I do
that for strong for the stronger carotitis or or charactis.
(19:36):
It's not getting better. Patients cannot get pregnant on it either,
so if they're unsure. If you're unsure, you can get
a pregnancy test before starting them on it. The one
thing to know about multephyzine is that it when when
the medicine is stopped, or actually even during the medication.
You can get it in or after suff you can
(19:57):
get an inflammatory response in the corny. Yeah, and it's
said to perhaps be from either the cysts or they
can't do it, bugs that are dying off. And there's
a type of inflammatory reaction so which you can see
even with other medications, but I've seen it more within
the toughestine, so that you may have to add some
steroids to decrease an inflammatory response. Even if you think
(20:22):
the infection is getting better. Again, it's not always easy
to tell it's infection getting worse or inflammation. But typically
their pain is getting better, the rent is getting better.
But they can get kind of these sei types or
more inflammatory infiltrates during treatment.
Speaker 1 (20:40):
Yeah, so how do you know if they're getting better?
You mentioned that there because I remember having a patient
once where their pain wasn't getting better. But my mentor said, no,
that that can happen sometimes, it doesn't mean that the
infection isn't improving, whereas in a bacterial carotitis a bacterial ulcer.
For me, the most indicative thing when they come back
(21:00):
into the office is I say, are you in pain?
And they say no, it's actually better, But I can't
see the redness's battle say I'm good or not. I'm good. Yeah,
pain in bacterial care of titis. That's resolved. If that's
getting better, then I know we're on the right course,
whereas an acanta me. But that isn't necessarily as reliable
an indicator.
Speaker 2 (21:19):
Correct. Yes, it's certainly not as fast. They can still
they can have pain for days and days or even
weeks into treatment. Even though we think the treatment is working,
they can still have pain. But in general I want
to see the pain get better. But it's certainly a
much longer time course. You're absolutely right. Oh sorry, so
then sorry, let me go back and step. Those are
my kind of main three medications. Obviously you need pain
(21:41):
medications too. You want a monitor for glaucoma et cetera?
What other a can't meds do? I sometimes use with
much less evidence. Sometimes I use topical bori conasole. Sometimes
I'll use an oral antifungal like wori or flu condazole
or post a condosol. But sometimes I'll use those medications.
I think there's a lot less evidence that those are helpful.
(22:04):
I don't use clorhexidine as much just because I'm using PHMB.
Those are two are in the same family, But you
can similarly use clorhexidine basically the same percent pour h
two percent at the same dosage. Now, there's a relatively
recent article out of more fields looking at a stronger
concentration of PHMB. They used zero point zero eight percent
(22:29):
PHMB at a pretty frequent dosing and they compared it
in a double mask study with the point zero two
percent PHMB that most of us use and broline. So
one group had the lower dose PHMB and brolin and
the other group had the four time strength dose. And
(22:51):
in this pretty reasonable size freak anthemba multi center study,
they showed equivalents of those two regiments. So I've recently
asked our pharmacy can you compound the point eight percent
PHIB and they're looking into doing that. They're concerned about toxicity,
but the study that was published showed no increase in
(23:12):
toxicity with the point oh eight percent.
Speaker 1 (23:15):
And in the point oh eight percent group were they
not using brolin? Correct So to summarize your your typical
algorithm here is PHMB point oh two percent every hour
and often brolling every hour. What might be something you're
going to do moving forward is instead of that, you're
(23:35):
going to cut out the brolin and just increase the
concentration of PHMB point oh eight percent. And for those
who direct that, chlorhexadine is in the similar family of that, right,
So I think that's that's that's pretty clear. That's a
good And like you said, everybody's going to have different approaches.
Some people are going to be stronger on the anti fungals,
(23:56):
even though as you said, maybe there isn't as much evidence.
But for people listening to this, it's out from a
no PHMB and brolin started every hour. If it's really bad,
you can use the miltapazine. How long are patients overall
on the PHMB and the broleine, because I've seen patients
on this for months obviously not on Q one. Ah,
you're gonna say for it down, But when you're prescribing it,
(24:19):
and when you're speaking to the patient and letting them
know they're going to be on these for a while,
are we we're talking months here?
Speaker 2 (24:25):
Months? Yes? Correct? And it depends on on the critical response.
Typically you know they'll be on both medications, and then
as I caper them down, I last the patient is
one of these much more painful than the other, And
oftentimes they say the broline is, but not always, so
I'll typically taper the one that's much more painful faster
(24:46):
than the other one, and I'll eventually stop that one.
As I caper them down, now i'll stop one keep
the other one, so I don't do too many changes
at one time, because if they get worse, I'm not
sure exactly which which medication was helping. So I'll tape
with the brollying a little bit, and I'll tape with
the PHMB a little, then the brillian a little, phm
B a little, and I'll usually stop the browling while
they're still on some PHMB. Often during that process I
(25:10):
add some steroid drops. Not at the beginning, and if
I suspect they can't and me, but early on, I'm
stopping the steroids. But after a few weeks, I will
often add some steroid because their eyes so red, so painful,
so inflamed, or they're getting quite one of these inflammatory
reactions from we think they can't but dying off, and
I'll start that again, not right away, but after a
(25:32):
few weeks and not not super high groused, maybe pread
two three four times a day. See how that does.
If I start a steroid, I'll see that bat usually
within a few days, just to make sure they're not
really getting worse.
Speaker 1 (25:45):
So we know that for bacterial carotitis, there's been evidence.
Speaker 2 (25:49):
Yeah, this scut trial didn't show great improvement with steroids,
maybe a little bit, especially in the really severe patients,
except for more excellent with the steroids make things worse.
Speaker 1 (25:59):
So we know that for bacterial carotitis, there's some evidence
from the Scott trial maybe adding steroids within the first
few days actually will help. On the polar opposite end,
we know that HSV epithelial carotitis, you definitely don't want
to use steroids because it's going to make it worse.
In the earlier days of somebody's they can't the MEBA infection.
Are they more on that HSV side where if you're
(26:20):
using steroids it's going to make it far worse. Yes,
So that's why you wait the several weeks. It's kind
of like you have the same approach as HSV and
fungal infections where steroids are a pretty big no no.
But later, I'm granted, because it's such a long process.
At some point, as with most things, steroids are going
(26:40):
to come on board.
Speaker 2 (26:42):
Yeah, and I'll tape with those slowly too.
Speaker 1 (26:45):
Chris, I think you've done an excellent job at summarizing this,
and you said we could do this in half an hour,
and that's basically what we've done. But I'm sure there
are some other points that you have. Are there any
other main takeaways or big points, blind spots that you
think people have that you want to address in regards
to a cantomba.
Speaker 2 (27:03):
I think I think I pretty much made my points
where soft cutting lens where with HSV you have to
think about a cant and meva, especially if the HSV
is not getting better, and in anybody with HSV that's
really not getting better, you really have to think about it.
I mean, I'm not saying they all have it. You know,
there's a thousand times more HSV patients out there than
a canto MEVA patients, but you have to think about it.
(27:26):
When things aren't going the way they should be going,
doesn't mean there aren't HSV patients that go down the
tubes when we don't have a cantamba. But you need
to think about it. And then the question comes up,
you know, when do you visually rehabilitate these patients? Okay,
any catamba they have, they're retreated, you have three months
(27:48):
intensive treatment and six months finally they're off of medications
than a bad central scar. What do you do? And
the answer is the only real option. I mean, you
could try contact lens. The scar's not that bad. It's
mainly irregularity or scleral lens. But many of these patients
will need usually to penetrate in graph because at this
point they're in the thel and probably isn't so great either.
(28:10):
You can think about a day olka, but most of them,
I think we'll end up eating a PK. How long
do you wait? And there's no right or wrong answer
to that, but I wait at least a year just
to make sure that there's no You know, these these
cysts are like bugs going going kind of into their bunkers,
and they could they can be live viable cysts in
their bunkers, not causing any problems, and they can come
(28:32):
out three six months you know later, especially if you
stress it with steroid drops or with surgery. So you know,
I wait at least a year, sometimes longer depending on
the patient before doing surgery, and really bad a cant
to me. But you can get significant cataract formation. You
also get significant iris damage. My most recent patient has
(28:53):
a pretty dilated pupil, even though they don't have any
kind of super o vi as iris translimanation or atrophy,
but obviously there was damage done. They were on atophine
at one point, but they were not atoping for for
a long long time and the people still dilated. So
there are other anti segment issues that you can get
what they can't to me, But so intersegment surgy is
(29:15):
not always so easy.
Speaker 1 (29:17):
Bugs in the bunker. I like that analogy.
Speaker 2 (29:19):
Yeah, So I tell patients, I say they bunker, They
go to their bunker. They're hiding, hiding, hiding. That's why,
you know, we need to make sure that we do
things very very slowly, because when they kind of peek
out of the bunker, you still have medicine on board
that's killing them.
Speaker 1 (29:34):
And the good news is, and you see a lot
more of this than I do, I'm sure one because
you're at Wills and two because you've been in practice
longer than me. But there are some there are some
cases when you do catch it early where you can
actually get a pretty good result with ach.
Speaker 2 (29:47):
Oh. Absolutely if you catch in the pseudodendrite stage. Then
not all the time, but often you know, these eyes
can can look great, perfect, maybe some mild haze, you know,
but be twenty twenty and you know, never have a
problem the rest of their life. That's what you want
to catch it.
Speaker 1 (30:07):
And I think you've given us the tools and the
information to do that. I think you've taken a really scary,
to be honest for most people, and complicated topic, and
you've simplified it in terms of what we need to
look for, what are the main signs, and then just
your treatment paradigm. I think for me makes me a
little bit less intimidated by that diagnosis once I have
it understanding that, like with many things, there's multiple different
(30:30):
ways you can treat it. There's multiple different approaches. You
can look online and look at one hundred different research
papers that suggest multiple different things. But you're working at
WILLS and you're doing a pretty good job. So following
that certainly certainly is reasonable for people listening to this.
Doctor Chris Rapuano, thank you so much for joining me
again on the podcast. Deeply appreciated and congratulations. You were
(30:51):
recently ranked one of the top one hundred ophthalmologists in
the world. That's a huge accomplishment and the thrilled to
have you on here.
Speaker 2 (30:59):
Great Thanks me. It was fun today out to talk
to you and enjoyed doing the podcast. We'll do it
again sometime.
Speaker 1 (31:04):
Sounds good. Thank you everybody for listening to another episode
of blind Spot. Have a great day.
Hey everybody, I'm zaeo Mednik and welcome to another episode
of blind Spot. This episode is sponsored by THEO Pharma Canada.
THEA pharm of Canada is the Canadian subsidiary of THEA,
Europe's leading pioneering and innovative eye health brand. Founded in
nineteen ninety four by Henri Schibre. With five generations of history,
the Chubret family has been dedicated to I care for
(00:32):
more than one hundred and fifty years. Their commitment to
improving lives is born of their pioneering spirit. They continue
to lead the worldwide preservative free movement in eye care.
They've created innovative delivery systems. They've focused on making products
accessible and cost effective for patients. They live this mission
every day because everyone should have the same opportunities to
see the world through healthy eyes. So thank you THEO
(00:55):
Pharmer Canada for supporting blind Spot. A cant Amba cara
titis can be one of the most devastating diagnoses in ophthalmology,
as it can wreak havoc on the cornea unlike few
other microbes on the same token. If caught early, A
canthony that can be treated quite efficiently and effectively, and
patients cannot have minimal, if any, long term visual sequelle.
In some cases, given a cantemiba is such a dread diagnosis,
(01:18):
just the thought of it can invoke fear into the optalmologist.
And while many of us might have a basic approach
to acanthemiba, we also surely have blind spots in our
diagnosis and management of this condition, as evidenced by many
patients being diagnosed weeks after it occurs. I'm joined today
by Chris Rapuano. Doctor Rapuano is a nationally an internationally
recognized expert in cornial diseases, is chief of the Will's
(01:40):
I Cornea Service and a professor of ophthalmology. He's authored
several books, including the Will's I Manual, which is known
by Everybody and I Care, and he was recently offered
on The Ophthalmologist Powerless of twenty twenty four, recognizing him
as one of the top one hundred most influential ophalmologists
in the world. Doctor Rappoano joined us previously on our
episode of the podcast discussed recurrent corneel erosion syndrome, and
(02:02):
today he joins us again to discuss a can't amba
all right, So doctor Chris Rapuano, welcome back to the podcast.
Second time. Very very exciting, more so for me than
for you, but very exciting.
Speaker 2 (02:12):
Oh thanks, sale happy to be here.
Speaker 1 (02:14):
So we were chatting about doing a second episode and
we were throwing a few ideas around and you suggested
a cantamba. I said, maybe that's a little too big,
which may have reflected the fact that a cant amba,
even as a cornea special stresses me out a little
bit because there's so much about it. And he said, no, no, no,
I think we should do a cantamva. It's an important
topic and I could not argue with the importance of
(02:36):
the topic, and definitely something that fits into this theme
of blind spot where a lot of us know you
don't want to miss a cantamba, but clearly there's a
blind spot reflected in the fact that diagnosis is often
so delayed. So let's talk first. I guess about why
you felt this was such an important topic to do.
Speaker 2 (02:55):
Well, A can't tomba, as we all know, is a
rare condition, and rare conditions are things that we kind
of keep out of our mind and really just don't
think about. And that's the problem with a canton meba
some some patients that we see. We see lots of
patients of corneill ulcers, but if you don't think about
a diagnosis, you won't make the diagnosis. And I'm on
(03:19):
the board of OMIC, the Atomic Richard Insurance Company, which
ensures about half the ophthalmologists or who go who go
for private I'm not practice shurans in the United States,
and we have seen several cases recently in the past
year or two of misdiagnosed slash undiagnosed a canton meba.
(03:40):
Like otherwise good doctors, sometimes corneus specialists who just don't
think about the diagnosis and and eyes have really gone
down the tubes. So you know, it's something that we
I think about all the time. Just as a tertiary
care hospital, teaching hospital. You know, I'm running through the
different ends with the residents and the fellow so it's
(04:02):
part of that. But it is missed not infrequently, and
the sequeli are potentially devastating if if you missed a
diagnosis for too long. But that's why I think it's
an important thing to talk about.
Speaker 1 (04:17):
So, as you said, there can't Amba is notorious for
having a delayed diagnosis. Often people are shuffled around to
multiple ie care specialists. Maybe treated for simplex because you
can have that dendrotic appearance. Maybe treated for a bacterial
care titis because it can have that appearance too. And
what are some of your tips for off the bat
(04:38):
thinking this is a cant amba so you don't wait
for that right because obviously you want a culture and
you want to do you want to take swabs and
for culture PCR and we'll talk about that, but still
there can be a delay for that to even come back.
So some of your tips so people don't run into
this problem, aside from just maybe one thing which is
(05:00):
important being more aware and conscious of it.
Speaker 2 (05:04):
My biggest tip is if we have a soft contact
lens where who comes in with a diagnosis of herpes
simplex carotitis to me, sure they can have herpe simplex
just like anybody can. But you have to think about
a cant a eva. That is has to be in
your differential and you can say, thought about cantinba, it's
(05:27):
a classic dendrot it's not Acanthinba. Doesn't go along with
and you're done, And that's fine if you don't think
about the diagnosis of a cantin eva in that particular case,
then you may miss it. And that's what's happened in
numerous of these malpractice cases that I've reviewed, is they
were either diagnosed by the doctor who's being sued, but
(05:48):
more commonly they're diagnosed by the referring doctor. Oh, this
patient has had herpes for a few weeks, not getting better.
I'm sending them to you, and then you get the diagnosis, Oh,
they have herpes there for I'm not thinking about anything else,
and that doesn't work. I mean, it doesn't work when
it's a caan't the meba. And why were they originally
(06:10):
diagnosed with herpes? In these cases, they probably did not
have herpes, but they probably had a pseudodendritic epitheliopathy, So
a funny looking kind of dendritic pattern in the cornea
that you can see with relatively early acant the MEBA.
And if you diagnose herpes and go down that pathway,
(06:30):
then you're delaying your diagnosis of a can't and meba.
So these are soft gutting lens wearers, and they often
have a history of it a few days, even a
couple of weeks of symptoms. They may have severe pain,
but these patients did not have severe pain. None of
them had severe pain that you kind of at least
early on that you kind of think, oh my god,
(06:51):
could this be a cant the meba. And when they're
not severe pain, you may think of herpes as I mean,
the nerves are so healthy, they're neutrophic. That is the
other thing I would. I would The other kind of
clue is you do not have to have severe pain
to have the diagnosis of ACAMT the meva. Yes, that's classic,
and if you have the severe pain, you may make
the diagnosis earlier, but you don't have to have it.
(07:13):
You still have to think of a camp and meba
very succinct.
Speaker 1 (07:17):
A very good point there about contact lens where who's
diagnosed with AHSV And it's really tempting in all of medicine,
and I mean for ophalmologists and optometrists too. Or listen
to this when you're given referral note which has a
diagnosis on it, because it's natural. It's natural to think, oh,
this is what it is, Okay, how can I better
treat this? They're sending this to me because I'm a
(07:37):
corny specialist. What else do I have up my sleeve
to treat HSV? But it's not HSV? What are some
of the other classic things on history here? I'm thinking
swimming lakes, contact lenses. What are some other features that
we should be asking about. It's kind of two questions,
and do we understand how a can't the meva actually
(07:58):
develops in these situations?
Speaker 2 (08:01):
Well, so the first part is kind of predisposing factors
soft counting lenswares by far the top predisposing factor, and
just saw cod answer alone with nothing else. But you know,
swimming pools, lakes, ocean, a hot tub, you know, probably
even higher on the list. And then the other one
is trauma, trauma with any trauma or trauma with getting
(08:24):
something kind of in the eye. We know that acanthy
be was ubiquitous. It lives everywhere. You can culture it
all over the place. But then question is, well, if
it's all over the place and everywhere, why do some
people get it? I personally don't have a great reason.
I suspect that the contact lenses have caused some microabrasions
of the cornea and that just allows the acantho be
(08:45):
able to get in you know, why do most people
have it in one eye and not both eyes? Although
I have seen patients, even my most recent patient had
it very mild in one eye and severe in the
other eye, so you can get in both eyes. So
I don't know. I don't think we exactly exactly why
that happens. The other thing is if a patient's being
(09:05):
referred in for herpe simplex then and they've been under
good treatment for herpe simplex, then you have to think
why is the herpe simplex not getting better if they're
being treated well. Or if I'm set to patient with herpes,
I treat them for herpes and I see him back
a week later, I'm and I'm giving them kind of
(09:25):
a full court press treatment for herpes, and it's not
getting better, even if I didn't think of a canthemya
the first day I saw them. If herpes treatment is
not getting better, then you need to think about akatama.
And the problem was in these cases that I mentioned,
they saw them numerous visits and never thought about ach.
Speaker 1 (09:48):
Is there always something to scrape? And what I mean
by that is sometimes sometimes somebody might not have an
epithelial component to that of cantemba perhaps or maybe that's
maybe that's not the case, and then you're wondering, hmm,
this looks strange, but I don't want to create an
epithelial defect to swab. And sometimes I have that debate
in general with correctly going away, what's your thought process
(10:11):
on that? And I mean, how important really is that
swab and that diagnosis on PCR typically for moving forward.
Speaker 2 (10:20):
Yeah, So there are lots of different ways to try
and make the diagnosis of a cant To MEBA, obviously
you've got the history and the exam, but at WILLS
we will typically do an epithel scraping and two different
scrapings sheets of epithem and send it to our pathologists
around the Eagle and Tatanamilman, and they're excellent at finding
just searching, searching and finding acanthemi the cists. Other You
(10:42):
could also send a scraping for cultures, you know, an
you call it overlay culture. You can send it for PCR,
which which can take time, and then you can use confocal,
which my cross could be, which I don't have at WILLS.
But those are other ways to make the diagnosis. Sometimes,
as you suggested early acantemba tends to be in the
(11:03):
epithelia you see epitheliopathy. That's the ideal time to make
the diagnosis because it's in the epithelium and it'll show
up much more easily on culture and on studies. The
problem comes up when it later several weeks after the
acanthomba started. We think that the acanthemba organisms and sys
(11:25):
kind of leave the epithelium and go into the stroma
and are now if you scrape the epithelium, epithelium is now
pretty normal or doesn't have the the acafeu bid in,
but it is in the stroma. So at that point
we don't necessarily have a confirmed diagnosis of acantemba. And
what do we do? So to answer first question, I
(11:47):
will do a scraping anyway, because if I can show
I will create an epithel defect. Certainly, if there's any
epitheliopathy that looks like maybe acantemiba, I have no problem
creating a big epithelial defect. And in acantomba typically that
heals pretty well as opposed to bacterial ulcers which may
not heal quite as well. Et cetera. But I have
no problem doing that. To make the diagnosis. Once it's
(12:10):
in the stroma, it's harder to make that diagnosis. And
I will treat empirically. Based on my suspicion. I think,
oh my goodness, it's the history the exam goes with acantamiba.
I'll do my scraping today. I'll even start my treatment
even before I get an answer from the scraping. I
love a confirmation because the medications are toxic and they
(12:33):
go for a long, long time, and I really want
to be sure I've got the correct diagnosis subjecting the
patients to this. But I'm unable to get that, but
I'm really suspicious of it. I will still treat them.
Speaker 1 (12:44):
And that was my next question. Sometimes there's this debate.
You obviously want to have the diagnosis with PCR culture,
especially because this is going to be long treatment typically,
so you write long and toxic and painful, so you're
going to commit them to that. I know it's important
to treat it right away, but sometimes there is that
debate in somebody. Let's say they do have an epithelial defect,
(13:06):
they do have a pseudodendrite, and you send it and
it's going to be a few days before you get
it back. I guess what is your threshold when you'll say,
you know what, we can wait a few more days
until we get this. We can get this back to
make sure we're treating the right thing before these toxic,
expensive medications, or we should we should start right away.
And I as I asked that, I realized that with
(13:28):
many things, the answer is the answer is it depends.
And I'm guessing. I'm guessing to go back to what
you said. If you had a contact lens where who's
been diagnosed with HSB, who's been on Valley cycle he
or a cycler has been on gan CYCLVI or JEL,
it's been on everything and they're in a ton of pain,
or there's no history of HSV. In that situation, you
might just say, okay, let's let's scrape, but start right away.
Speaker 2 (13:52):
Yeah, you're absolutely right. It depends, and it depends on
my clinical suspicion. How should in the mind they do
have a canton eva just by you know, the history
and the symptoms and the clinical appearance. And if I'm
maybe maybe not, then I don't think there's necessarily terrible
(14:15):
harm in waiting a few days till I get you know,
a path diagnosis or culture or PCR diagnosis. If I
am pretty certain it's a canton meba, I will start
them that day and then I'll send things for a
and I'll send things for you know, bacteria, fungus too.
And then obviously if it comes back some weird fungal
(14:37):
ulcer that I wasn't suspecting, I say, uh, parked up
the wrong tree stop by a anthoniameds. And now treat
my fungal diagnosis. That can happen on rare occasion where
you just send for things and an unsuspecting thing shows up,
you've got to change your plan. But if I'm pretty
sopeicificate canton eba, I will treat that.
Speaker 1 (14:58):
For the actual swave. When you're getting a sample, you
mentioned you want a sheet of epithelium, and I've heard
that before. That kind of in contrast to when I'm
doing a bacterial culture, where I I'm kind of just
going at the the infiltrate that's obviously there. Right, I
am more cognizant in a camp of me, but to
(15:19):
make sure I get some actually a sheet of epithelium,
like you said, surrounding epithelium that's supposed to be higher yield.
Is that correct?
Speaker 2 (15:28):
Yeah? Correct, especially for us at Will's. We're setting it
for a pathology. We're taking that sheet and we're laying
it down ideally as a sheet on you know, the
glass micro slide, and then then we said that we
walk it right up to pathology. Actually, nowadays they've given
us the actual fixative to actually fix it in the
Cordia office and then bring it upstairs to micro and
(15:50):
then they'll read it within twenty four hours. So we
get a pretty rapid turnaround on that. And sometimes I'm
sure it's a caret and meba and and the the
epithelium is negative for it can't amba, and then I'll
keep treating until I decide not to.
Speaker 1 (16:09):
So if you get a positive, obviously you know it's
a can't amba. If you get that doesn't necessarily preclude
the diagnosis.
Speaker 2 (16:15):
Correct, that's correct. And again it'll go by my suspicion.
If I'm very suspicious, I'll keep treating, so so then
I might stop or if I sometimes patients are sent
in for a rule at a can't amba, and I'll say,
I don't think that's what it is, but I'm really
not one hundred percent sure I will send that up,
(16:36):
not treat them and wait for wait for UH pods
of diagnosis to start treating Chris.
Speaker 1 (16:42):
I think for me, what's most daunting about a can't amiba.
And I am a cornea specialist, but my naivete is
on full exposure on this podcast, is that there's just
so many options for treatment. So for me, it's not
I mean, the diagnosis is obviously something I don't want
to miss and I'm concerned about it, but it's often
that when I do decide, okay, this might be a
(17:03):
canth amba, I've got charts on my phone, I go
to the Wills Manual, which you which you created. There's
so many options, right, there's chlorhexadine, there's PHMB, there's topical iconasole,
there's oral vericonisole. And when there's so many things which
work differently in their mechanisms in how they target a
(17:24):
cante me, but it can be a little bit daunting.
I think to people in what the approach is? What
is your treatment approach to a cant am memba.
Speaker 2 (17:34):
Yeah, it is. It is a big issue because there
are lots of different treatments out there, and you talk
to different specialists all over the country or the world
for that matter, and they each have their own kind
of regimen that they use.
Speaker 1 (17:44):
So we're gonna go We're gonna go with the rappawano
regimen here.
Speaker 2 (17:47):
Yeah, there's there's there's no right or wrong to this.
But what I've done in the past is I use PHMB.
Our pharmacy will make that up. We've used the point
oh two percent PHMB, which is probably hex methylene bikewanide,
which is the baquasil kind of pool cleaner that that's
in a diluted form, and we'll start that every hour
(18:07):
around the clock. In general, what I've done in the
past and what I still do actually my current treatment
is I will also use broline for parmudine drops, which
are not available in the US, but I will get
it from an internet pharmacy and then basically give it
to the patient. And that's also every hour around the clock.
And that'll be for usually again depending on the severity
(18:31):
and how they tolerate it, for the first week or
two or three, but usually maybe the first week, and
then I'll cut down the nighttime meds W two and
then cut those again. So I stopped the nighttime meds
to get patients from sleep and then see how they're doing,
and then slowly cut down those two other medications. If
it's really bad, I will also use noltefazine pills. These
(18:53):
are pills that are kind of fully FDA approved for
kind of protozo in the brain, but have some type
of compascit use approval for a kantemybic caratitis. So maltepazine
is a pill that's I think it's fifty milligrams. It's
I think it's tight today, two or three times a day,
(19:14):
and it's for a one month course is what I'll
typically give it for. You need to check their liver
function test or couldney function test, and I get a
CBC two before I start it, just to make sure,
and they'll check it every few weeks that they're on
the medication, or have their interness check that. It's a
pretty strong medication, but it can work well. I do
that for strong for the stronger carotitis or or charactis.
(19:36):
It's not getting better. Patients cannot get pregnant on it either,
so if they're unsure. If you're unsure, you can get
a pregnancy test before starting them on it. The one
thing to know about multephyzine is that it when when
the medicine is stopped, or actually even during the medication.
You can get it in or after suff you can
(19:57):
get an inflammatory response in the corny. Yeah, and it's
said to perhaps be from either the cysts or they
can't do it, bugs that are dying off. And there's
a type of inflammatory reaction so which you can see
even with other medications, but I've seen it more within
the toughestine, so that you may have to add some
steroids to decrease an inflammatory response. Even if you think
(20:22):
the infection is getting better. Again, it's not always easy
to tell it's infection getting worse or inflammation. But typically
their pain is getting better, the rent is getting better.
But they can get kind of these sei types or
more inflammatory infiltrates during treatment.
Speaker 1 (20:40):
Yeah, so how do you know if they're getting better?
You mentioned that there because I remember having a patient
once where their pain wasn't getting better. But my mentor said, no,
that that can happen sometimes, it doesn't mean that the
infection isn't improving, whereas in a bacterial carotitis a bacterial ulcer.
For me, the most indicative thing when they come back
(21:00):
into the office is I say, are you in pain?
And they say no, it's actually better, But I can't
see the redness's battle say I'm good or not. I'm good. Yeah,
pain in bacterial care of titis. That's resolved. If that's
getting better, then I know we're on the right course,
whereas an acanta me. But that isn't necessarily as reliable
an indicator.
Speaker 2 (21:19):
Correct. Yes, it's certainly not as fast. They can still
they can have pain for days and days or even
weeks into treatment. Even though we think the treatment is working,
they can still have pain. But in general I want
to see the pain get better. But it's certainly a
much longer time course. You're absolutely right. Oh sorry, so
then sorry, let me go back and step. Those are
my kind of main three medications. Obviously you need pain
(21:41):
medications too. You want a monitor for glaucoma et cetera?
What other a can't meds do? I sometimes use with
much less evidence. Sometimes I use topical bori conasole. Sometimes
I'll use an oral antifungal like wori or flu condazole
or post a condosol. But sometimes I'll use those medications.
I think there's a lot less evidence that those are helpful.
(22:04):
I don't use clorhexidine as much just because I'm using PHMB.
Those are two are in the same family, But you
can similarly use clorhexidine basically the same percent pour h
two percent at the same dosage. Now, there's a relatively
recent article out of more fields looking at a stronger
concentration of PHMB. They used zero point zero eight percent
(22:29):
PHMB at a pretty frequent dosing and they compared it
in a double mask study with the point zero two
percent PHMB that most of us use and broline. So
one group had the lower dose PHMB and brolin and
the other group had the four time strength dose. And
(22:51):
in this pretty reasonable size freak anthemba multi center study,
they showed equivalents of those two regiments. So I've recently
asked our pharmacy can you compound the point eight percent
PHIB and they're looking into doing that. They're concerned about toxicity,
but the study that was published showed no increase in
(23:12):
toxicity with the point oh eight percent.
Speaker 1 (23:15):
And in the point oh eight percent group were they
not using brolin? Correct So to summarize your your typical
algorithm here is PHMB point oh two percent every hour
and often brolling every hour. What might be something you're
going to do moving forward is instead of that, you're
(23:35):
going to cut out the brolin and just increase the
concentration of PHMB point oh eight percent. And for those
who direct that, chlorhexadine is in the similar family of that, right,
So I think that's that's that's pretty clear. That's a
good And like you said, everybody's going to have different approaches.
Some people are going to be stronger on the anti fungals,
(23:56):
even though as you said, maybe there isn't as much evidence.
But for people listening to this, it's out from a
no PHMB and brolin started every hour. If it's really bad,
you can use the miltapazine. How long are patients overall
on the PHMB and the broleine, because I've seen patients
on this for months obviously not on Q one. Ah,
you're gonna say for it down, But when you're prescribing it,
(24:19):
and when you're speaking to the patient and letting them
know they're going to be on these for a while,
are we we're talking months here?
Speaker 2 (24:25):
Months? Yes? Correct? And it depends on on the critical response.
Typically you know they'll be on both medications, and then
as I caper them down, I last the patient is
one of these much more painful than the other, And
oftentimes they say the broline is, but not always, so
I'll typically taper the one that's much more painful faster
(24:46):
than the other one, and I'll eventually stop that one.
As I caper them down, now i'll stop one keep
the other one, so I don't do too many changes
at one time, because if they get worse, I'm not
sure exactly which which medication was helping. So I'll tape
with the brollying a little bit, and I'll tape with
the PHMB a little, then the brillian a little, phm
B a little, and I'll usually stop the browling while
they're still on some PHMB. Often during that process I
(25:10):
add some steroid drops. Not at the beginning, and if
I suspect they can't and me, but early on, I'm
stopping the steroids. But after a few weeks, I will
often add some steroid because their eyes so red, so painful,
so inflamed, or they're getting quite one of these inflammatory
reactions from we think they can't but dying off, and
I'll start that again, not right away, but after a
(25:32):
few weeks and not not super high groused, maybe pread
two three four times a day. See how that does.
If I start a steroid, I'll see that bat usually
within a few days, just to make sure they're not
really getting worse.
Speaker 1 (25:45):
So we know that for bacterial carotitis, there's been evidence.
Speaker 2 (25:49):
Yeah, this scut trial didn't show great improvement with steroids,
maybe a little bit, especially in the really severe patients,
except for more excellent with the steroids make things worse.
Speaker 1 (25:59):
So we know that for bacterial carotitis, there's some evidence
from the Scott trial maybe adding steroids within the first
few days actually will help. On the polar opposite end,
we know that HSV epithelial carotitis, you definitely don't want
to use steroids because it's going to make it worse.
In the earlier days of somebody's they can't the MEBA infection.
Are they more on that HSV side where if you're
(26:20):
using steroids it's going to make it far worse. Yes,
So that's why you wait the several weeks. It's kind
of like you have the same approach as HSV and
fungal infections where steroids are a pretty big no no.
But later, I'm granted, because it's such a long process.
At some point, as with most things, steroids are going
(26:40):
to come on board.
Speaker 2 (26:42):
Yeah, and I'll tape with those slowly too.
Speaker 1 (26:45):
Chris, I think you've done an excellent job at summarizing this,
and you said we could do this in half an hour,
and that's basically what we've done. But I'm sure there
are some other points that you have. Are there any
other main takeaways or big points, blind spots that you
think people have that you want to address in regards
to a cantomba.
Speaker 2 (27:03):
I think I think I pretty much made my points
where soft cutting lens where with HSV you have to
think about a cant and meva, especially if the HSV
is not getting better, and in anybody with HSV that's
really not getting better, you really have to think about it.
I mean, I'm not saying they all have it. You know,
there's a thousand times more HSV patients out there than
a canto MEVA patients, but you have to think about it.
(27:26):
When things aren't going the way they should be going,
doesn't mean there aren't HSV patients that go down the
tubes when we don't have a cantamba. But you need
to think about it. And then the question comes up,
you know, when do you visually rehabilitate these patients? Okay,
any catamba they have, they're retreated, you have three months
(27:48):
intensive treatment and six months finally they're off of medications
than a bad central scar. What do you do? And
the answer is the only real option. I mean, you
could try contact lens. The scar's not that bad. It's
mainly irregularity or scleral lens. But many of these patients
will need usually to penetrate in graph because at this
point they're in the thel and probably isn't so great either.
(28:10):
You can think about a day olka, but most of them,
I think we'll end up eating a PK. How long
do you wait? And there's no right or wrong answer
to that, but I wait at least a year just
to make sure that there's no You know, these these
cysts are like bugs going going kind of into their bunkers,
and they could they can be live viable cysts in
their bunkers, not causing any problems, and they can come
(28:32):
out three six months you know later, especially if you
stress it with steroid drops or with surgery. So you know,
I wait at least a year, sometimes longer depending on
the patient before doing surgery, and really bad a cant
to me. But you can get significant cataract formation. You
also get significant iris damage. My most recent patient has
(28:53):
a pretty dilated pupil, even though they don't have any
kind of super o vi as iris translimanation or atrophy,
but obviously there was damage done. They were on atophine
at one point, but they were not atoping for for
a long long time and the people still dilated. So
there are other anti segment issues that you can get
what they can't to me, But so intersegment surgy is
(29:15):
not always so easy.
Speaker 1 (29:17):
Bugs in the bunker. I like that analogy.
Speaker 2 (29:19):
Yeah, So I tell patients, I say they bunker, They
go to their bunker. They're hiding, hiding, hiding. That's why,
you know, we need to make sure that we do
things very very slowly, because when they kind of peek
out of the bunker, you still have medicine on board
that's killing them.
Speaker 1 (29:34):
And the good news is, and you see a lot
more of this than I do, I'm sure one because
you're at Wills and two because you've been in practice
longer than me. But there are some there are some
cases when you do catch it early where you can
actually get a pretty good result with ach.
Speaker 2 (29:47):
Oh. Absolutely if you catch in the pseudodendrite stage. Then
not all the time, but often you know, these eyes
can can look great, perfect, maybe some mild haze, you know,
but be twenty twenty and you know, never have a
problem the rest of their life. That's what you want
to catch it.
Speaker 1 (30:07):
And I think you've given us the tools and the
information to do that. I think you've taken a really scary,
to be honest for most people, and complicated topic, and
you've simplified it in terms of what we need to
look for, what are the main signs, and then just
your treatment paradigm. I think for me makes me a
little bit less intimidated by that diagnosis once I have
it understanding that, like with many things, there's multiple different
(30:30):
ways you can treat it. There's multiple different approaches. You
can look online and look at one hundred different research
papers that suggest multiple different things. But you're working at
WILLS and you're doing a pretty good job. So following
that certainly certainly is reasonable for people listening to this.
Doctor Chris Rapuano, thank you so much for joining me
again on the podcast. Deeply appreciated and congratulations. You were
(30:51):
recently ranked one of the top one hundred ophthalmologists in
the world. That's a huge accomplishment and the thrilled to
have you on here.
Speaker 2 (30:59):
Great Thanks me. It was fun today out to talk
to you and enjoyed doing the podcast. We'll do it
again sometime.
Speaker 1 (31:04):
Sounds good. Thank you everybody for listening to another episode
of blind Spot. Have a great day.
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