Intern Report 6.7

Case Presentation by Dr. Katherine Schulman

A little background:

27-year-old African American male seen as follows:

DRH ED:  7/15/2012: ( Time 0 )

C/C:  “My eyes are irritated.”

HPI:  bilateral eye irritation starting a month prior, mild photophobia, markedly injected, greenish discharge

Final Impression/Diagnosis:  Bilateral Conjunctivitis, discharged with Gentamicin ophthalmic solution, f/u w/ Kresge.

DRH ED:  7/22/2012: ( Time +7 Days )

C/C:  “My eyes still hurts.”

HPI:  Pt reports that he never did f/u with Kresge, but has been using the eye drops prescribed.  He states his eyes have gotten progressively more red, with increasing discharge, increasing photophobia, blurry vision, and foreign body sensation bilaterally.

Final Impression/Diagnosis: bilateral conjunctivitis, with evidence of pseudomembrane formation over the left eye.  Ophthalmology consulted and spoken with on phone.  They recommended atropine for symptomatic relief, erythromycin ointment, and artificial tears.  f/u w/ Kresge.

Pt did f/u w/ Kresge on 7/27/12 ( Time +12 Days ):  pt continued on medications as started in the ED, including Pataday (Olopatadine – is a mast cell stabilizer and a histamine H1 antagonist) drops for symptomatic allergy relief.

Final Impression/diagnosis:  Keratoconjunctivitis OU suspected.  Pt advised to f/u within a week (which he did not, next visit as described in case).

CASE:  10/30/2012 ( Time +107 Days )

C/C and HPI:  27-year-old African American male presents to Kresge Eye Institute, last seen in July.  Pt c/o blurry vision, eye discharge -yellow, injection, photophobia, and decreased visual acuity bilaterally for 4 months.

ROS:

Constitutional:  denies fevers, chills;

Eye:  redness, tearing, discharge, foreign body sensation, blurry vision;

ENT:  denies oral lesions;  Head:  denies HA;

GI: denies N/V/D;

GU:  denies dysuria, discharge;

Musculoskeletal:  denies joint pain/swelling, muscle aches;

Skin:  denies rash

Past Medical History: none

Past Surgical History: none

Medications: Only ophthalmic medications as in the previous months

Allergies: No known drug allergies

Family History: Hypertension

Primary care physician: None

Social History: Positive for tobacco and alcohol use.  Denies illicit drug use.

Physical Exam: (Kresge Eye Institute, thus only focused eye exam done)

Eye:

General:  sclera injected bilaterally, mucopurulent discharge, swelling to upper lids

Visual Acuity:  OD 20/30, OS 20/30

Pupils:  dim light 3mm -> bright light 2mm OD & OS

Confrontation:  Full to finger count OD & OS

Motility:  EOMI OD & OS

Slit Lamp Exam:

Eyelids – meibomian gland plugging and mattering OD & OS

Conjunctiva:  numerous, giant papillae and follicles OD & OS, 2+ injection OD,  1+ injection OS

Anterior Chamber:  deep and quiet OD & OS

Iris:  round and reactive OD & OS

Lens:  WNL OD & OS

247374_P1

Picture A

1.  Considering simply the duration of his ophthalmic complaints, which of the following should be considered on the list of differentials (please choose 2 below):

A).  Allergic Conjunctivitis

B).  Corneal Abrasion

C).  Chlamydial Inclusion Conjunctivitis

D).  Gonococcal Infective Conjunctivitis

2.  What is the most likely diagnosis in this patient?

A).  Allergic Conjunctivitis

B).  Corneal Abrasion

C).  Chlamydial Inclusion Conjunctivitis

D).  Gonococcal Infection

3.  What is the most appropriate treatment for this patient?

A).  Tetracycline 250mg QID x 14 days

B).  Ciprofloxacin 500mg PO BID x 10 days

C).  Vancomycin 15-20mg/kg IV QID plus Clindamycin 600mg IV TID x 5 days

D).  Erythromycin ophthalmic ointment BID x 21 days

 

Case Discussion:

1.    Considering simply the duration of his ophthalmic complaints, which of the following should be considered high on the list of differentials (please choose 2 options below):

A).  Allergic Conjunctivitis

B).  Corneal Abrasion

C).  Chlamydial Inclusion Conjunctivitis

D).  Gonococcal Infective Conjunctivitis

 

ANSWERS: 

1)         A, C

2)         C

3)         A

This patient has had ophthalmic symptoms for 4 months now.

Allergic Conjunctivitis:  Symptoms may be present for days, weeks, or months, as long as the offending agent is present.   Symptoms include:  itchy/ watery eyes and injected sclera.  TX: antihistamines, avoidance of stimuli, OTC lubricating/allergy relief eye drops, warm compresses.

Corneal Abrasion:  Injury to the superficial epithelial layer of the cornea heals fairly quickly – in days usually 24-48 hours, but certainly not weeks, nor months.  TX:  Erythromycin ophthalmic ointment QID x 10 days.  In contact lens users – d/c use of contacts and use topical antibiotic solutions with antipseudomonal coverage, such as: gentamicin, levofloxacin, etc.

Chlamydial Inclusion Conjunctivitis:  As described in the case above.  Can occur unilaterally or bilaterally in sexually active young people.  If not treated properly, inclusion conjunctivitis runs a course of 3-9 months or longer.  Details of disease and treatment are discussed below.

Gonococcal Infective Conjunctivitis:  Marked by profuse purulent (not mucopurulent) exudates and progresses quickly.  Exposure can lead to full ocular perforation and blindness within 24-48 hours.   Remember, every baby gets prophylactic treatment preferably with erythromycin ointment.

Other Common Conditions:

Blepharitis:  Inflammation of the eyelids.  Most often bilateral and symmetrical.  Patients often complain of a ‘gritty’ sensation.  Blepharitis is quite often chronic in nature, which can be managed with good eye hygiene/cleansing scrub and warm compresses.

Viral Conjunctivitis:  The most common!  Usually caused by adenovirus, following URIs and is quite contagious.  Patients present with redness, tearing, mild mucous discharge, and itchy/irritated eyes.  Often starts in one eye, but can easily spread without good hygiene.   Symptoms are self-limiting and don’t generally last longer than 4 weeks.  Care is supportive, with emphasis on good hand-eye hygiene.

**KRESGE EYE INSTIT ** UTES FINAL IMPRESSION:  Chlamydial conjunctivitis, bilateral papillary reaction worse on upper lids with mucopurulent discharge, multiple infiltrates with pannus formation.  Patient given a prescription for Tetracycline 250mg QID x 14 days.  Swab sent to lab – positive.

More about Chlamydial Inclusion Conjunctivitis:

Chlamydial conjunctivitis is a sexually transmitted disease, and it occurs most commonly in sexually active young adults. The disease is generally transmitted through hand-to-eye or orogenital spread of infected genital secretions. The incubation period can take up to 14 days.  An estimated 1 in 300 patients with genital Chlamydia develop conjunctivitis.

This is more commonly a unilateral eye infection, though it can be seen bilaterally as in the case above.

Patients may present with many of the following symptoms:  photophobia, foreign body sensation, decreased visual acuity/blurry vision, swollen lids, injected sclera, tearing, mucopurulent discharge.  Patients often awake in the morning with significant crusting of lashes and eyelids temporarily stuck together from the drying of the mucopurulent discharge.

The clinical findings seen in Chlamydial Conjunctivitis may also resemble other forms of infectious conjunctivitis.  Infected individuals often have preauricular adenopathy.  On closer exam through slit lamp:  a follicular reaction is the key feature of a chlamydial conjunctivitis, often involving the bulbar conjunctiva and semilunar folds, and papillary hypertrophy.  Take a look at the huge follicles in the pictures below.

6.7-b

Picture B

A diagnosis can be made based on the signs, symptoms, and the clinical suspicion.  A culture may be taken to confirm, but start oral antibiotic treatment immediately with high clinical suspicion.

Treatment:

Topical antibiotics are generally ineffective, and thus systemic antibiotics are the mainstay of treatment.  The following are used:  tetracycline, doxycycline, erythromycin, azithromycin.  A course of 2-3 weeks of oral antibiotics is warranted.

References:

Mandel, Douglas, Bennett:  Microbial Conjunctivitis:  Principles of Infectious Diseases, ed. 7  2009 (Ch) 110.

Sharma R, Brunette DD:  Ophthalmology: Rosen’s Emergency Medicine.  7th edition.  2010.  Ch 69:  859-876.

Root, Timothy.  Eye Infections.  Ophthobook.  Retrieved Jan 3rd, 2013 from ophthobook.com

 

 

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