Senior Report 8.4

Case Presentation by Mike Antoniolli, MD

 

A 28-year-old male presents to the emergency department with complaints of 3 days of eye pain, photophobia, redness, and decreased vision. The pain has become so severe that he has had 2 episodes of emesis. He denies any fevers, chills, recent infections, or URI symptoms. He denies any inciting event, trauma to the eye, dust or foreign body exposure.

Physical Exam:

General: Patient is holding a hand over his left eye leaning forward. Appears uncomfortable

Eyes: Left eye reveals scleral injection, epiphora, photophobia, and blepharospasm in addition to the findings shown in the image below. A contact lens is noted in the unaffected eye. Pain/photophobia was only partially relieved with proparacaine.

 

sr8.4

Questions:

1. What is the most likely outcome of this condition if he is not treated?

A. Corneal perforation

B. Intraocular hypertension

C. Dense cataract formation

D. Orbital compartment syndrome

E. Full blown AIDS

 

2. Given the patient’s corrective lens history, what is the most likely pathway that explains the above findings?

A. Bacterial keratitis->corneal ulceration->hypopyon

B. Caustic exposure->corneal abrasion->corneal liquefaction

C. Poor contact lens hygiene->bacterial keratitis->corneal abrasion

D. Rheumatologic illness->anterior uveitis->hypopyon

E. Childhood vaccinations->autism->ocular jenny mccarthitis

 

3. What additional finding would most likely be seen on slit-lamp examination of this patient?

A. Dendritic ulcerative lesions

B. Pingueculae and pterygia

C. Cell and flare in the anterior chamber

D. Very shallow anterior chamber and iridocorneal touch

E. Enucleation

 

Answers: 1. A, 2. A, 3. C

Discussion:

1. A. The patient has evidence of layering of white blood cells in the anterior chamber otherwise known as a hypopyon. In addition, there is evidence of conjunctival injection and significant corneal opacification. Given the historical information regarding contact lens use, it is likely the patient has developed a corneal ulceration secondary to infection. If the infection is left untreated, it can progress quickly resulting in erosion of the cornea and perforation. Once this occurs, the only way to restore the visual axis is corneal transplantation. Progression of the infection may lead to uveitis, iris prolapse, hypopyon, panophthalmitis and subsequent globe loss. A corneal ulcer is a medical emergency that necessitates aggressive treatment with topical antibiotics, with special consideration of pseudomonas in contact lens wearers. Evidence of endophthalmitis necessitates parental antibiotics. B) Although endophthalmitis may result in elevated intraocular pressure, it is unlikely to occur secondary to corneal ulceration. (C) Cataract formation is unlikely to result from this infectious process. (D) Orbital compartment syndrome typically occurs secondary to trauma or surgical procedures.
2. A. As described above, contact lens use predisposes patients to bacterial keratitis. Progression of the infection through the corneal layers results in ulceration, subsequent perforation, and the above sequelae. (B) Describes an alkali chemical injury to the eye. (C) Although extended wear is an associated risk factor for development of keratitis, the above patient’s symptoms and findings cannot be explained by a simple corneal abrasion. This is also hinted by his lack of analgesia following proparacaine drops, suggesting a process occurring deep to the cornea. (D) Rheumatologic illness can cause findings similar to the image above, but the history is not consistent with this.
3. C This patient has evidence of a hypopyon in the image above, which represents white blood cells layering within the anterior chamber. Cell and flare is simply evidence of inflammation with accumulation of white blood cells and protein within the anterior chamber. The patient also has clinical evidence of uveitis, and this is a classic finding. (B) Both of these are benign conjunctival overgrowths, not typically associated with infection. (D) This answer describes the findings expected on a patient with acute angle closure glaucoma.

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