Ophthalmic Signs
Case 1.1
A 21-year-old college student presents with a 2-day history of a red and painful right eye. He reports that he sleeps with his contact lenses that are prescribed for overnight use. He reports a similar, but less intense episode last year that resolved with topical antibiotics. Present this case to your attending.
 FIGURE 1.1 |
1.1 The Red Eye
PRESENTATION
Description: Figure 1.1 is an anterior slit lamp photo of the left eye. My attention is drawn to a large, circular corneal lesion with stromal opacification. There is significant conjunctival inflammation.
Differential Diagnosis: My number one differential diagnosis is bacterial keratitis, most likely Pseudomonas, given the history of contact lens wear. Keratitis can also be caused by other microbes such as fungal and Acanthamoeba.
History: We know he sleeps with contacts, but we need to know how long he wears them past their expiration date and how long he used continuously. Other items to inquire about include the brands of contact lens cleaners because some have been linked to atypical infections.
Exam: We need to measure the size of the hypopyon, corneal defect, and epithelial defect with fluorescein. I would perform a complete ophthalmic exam including dilation of both eyes.
Workup: We need to collect Gram stain specimens specifically searching for gram-negative rods. We also need to culture corneal scrapings in blood, chocolate, and Sabouraud agar.
Treatment: I would immediately start him on a fortified broad-spectrum antibiotic such as vancomycin and ceftazidime every hour to treat not only gram-negative bacteria like Pseudomonas but also gram-positive bacteria. I would persuade the patient to avoid contact lenses until the infections resolves.
Advice: I would discuss with the patient that Pseudomonas aeruginosa is a bacteria linked with contact lenses and it has potential of causing possible perforation. We have a guarded prognosis knowing that corneal ulcers of this magnitude will lead to a scar and permanent decreased vision.
Follow-up: I would follow the patient daily to monitor for progression until it resolves. If it does not improve after a few days, I would consider fungal infections. Surgical intervention may correct this scar.
TIP
Keep your presentations succinct.
Case 1.2
A 41-year-old bartender presents to your clinic with a 24-hour history of a red and painful left eye. She reports that a drunken customer hit her in her eye with his fist when she refused to serve him more alcohol. She reports her vision and pain getting worse over the last 6 hours. She has been treating her eye with over-the-counter drops to reduce eye redness. Explain your assessment and management to your attending.
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