CITW 8: A Painful Eye

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 47 year old male with a history of DM and HTN presents to the ED with a painful and red left eye, worsening over the past 24-36 hours.  It is associated with blurred vision, photophobia, headache, a foreign body sensation, and drainage. He tried saline drops without relief. He’s never had this before. He denies any trauma to the eye, although states he did leave his contacts in two nights ago. He denies fevers, chills, or any other associated symptoms.

Vitals: BP 156/87, HR 87, T 98.9 °F, RR 14, SpO2 100 % on RA

Notable PE: Visual acuity (R 20/30 L 20/50). EOMI intact, but painful. Pupils 3 mm and reactive. Lids everted and swept revealing no foreign bodies. Visual fields intact. Normal accommodation. Left eye findings below:

What’s the diagnosis?

Bacterial Keratitis (Corneal Ulceration)

Here are some quick facts:

  • Contact lens use is the single largest risk factor for bacterial keratitis.
  • Infections are primarily gram negative (pseudomonas), followed by gram positive infections (staphylococcus and streptococcus).
  • Common symptoms include conjunctival injection, ocular pain, eyelid swelling, reduced visual acuity, and photophobia.
  • Common physical exam findings include yellow or white stromal infiltrates, corneal edema, hypopyon, and cellular flare in the anterior chamber.
  • Feared complication is a corneal perforation which can result in endophthalmitis and vision loss.
  • Treatment includes empiric and broad spectrum topical antibiotic therapy (typically fluoroquinolone monotherapy) for several weeks to months, with every hour dosing in the first 24 to 48 hours.
  • Consider cycloplegics to prevent ciliary spasm and hence reduce photophobia.
  • Patients will need urgent opthalmology follow up and should discontinue any contact lens use.

Case Resolution:

The patient was started on broad spectrum topical antibiotics and followed up with opthalmology. He had successful resolution of his corneal ulcer.

Shout out to Dr. Kazakin for this case!

The contents of this case were deliberately altered to protect the identity of the patient. All content in this report are for educational purposes only. The patient consented to the use of these images.

See you next week!

Source: UptoDate

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