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[IndianaOD]

Hard to know without more info and some more images.

acanthaomeba or MRSA could be differentials I suppose.

Is that an ulceration or some sort of abrasion on the left?

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[Richard_Hom]

Dear IndianaOD,


This was the best I could do. Same left eye. Actually with this photo I was trying to see fi there was any anterior chamber reaction.

There is opacification of the corneal more at 4:00 than 9:00. Most of the damage was at 4:00 there.

 

[Richard_Hom]

This cleared up significantly with intensive therapy. Same eye, 5 days later. Topical steroid to be instilled in 2 days.

 

[IndianaOD]

Richard,


Could you give us some more history or other pertinent findings? Even with the picture you can't really see what is going on. I'm assuming non infectious from the response.

 

[Richard_Hom]

Here are my notes on this:

SUB 53 who has been referred by the ED for red painful

eye. She had originally consulted the ED at this hospital 2 days before on 12 Jul with red eye OS and was started on Ciprofloxacin. The original episode was 07/09 when she noticed OS red. It got worse by 7/12 and the vision plummeted on 07/12. She is a soft contact lens wearer who reports compliance to replacement and wearing schedule although she does admit to overnight wear for more than 1-2 nights. I am unaware of her brand because she did not bring any lens information. She has NKDA.

OBJ OD 20/20 and OS 3/FC. OS looks bad. See photo. The left cornea is swollen and hazy with white in the left half. Tapp 14 OU . Grade 3 flare but few cells. Hypothesia in the OS. No obvious ulcer formation.​

​

 

[Richard_Hom]

An unfortunate chap

 

[IndianaOD]

I was thinking the wound could have been neurotrophic.

 

[Richard_Hom]

I was busy these past several weeks or months. But this stuck in my mind:

See the history on my main web page.

Thanks.

 

[Richard_Hom]

For the intrepid, here is a case:
A 36 year old HM presented from the Emergency Department with a sudden onset of mild eye pain and photophobia of this eye. There is no reported history of risky work or trauma to this eye. The pain is greatest in the morning and subsides by mid-afternoon. Topical antibiotic therapy was started by the Emergency Department and I first saw the patient on the same day. From the Day 3 photo, it appears that antibiotic therapy has not been effective.

What are your working diagnoses? What is your plan of action?

 

[UWOpt2009]

Sounds like an RCE (or first occurence of). If no history of trauma, possibly secondary to EBMD? (can't tell from the pic).

Put on a BCL and continue antibiotics until epi defect is gone, then 50mg doxy bid x 2 weeks followed by qd x 6 weeks along with Lotemax qid x 1 month followed by bid x 1 month (as per Melton and Thomas).

 

[itek2OD]

FWIW, I agree with RCE. The trauma could be just opening his eyes every morning. Why can't the pt not survive on just Muro 128 5% 2x/d (qam & qhs) x 6 months. No antibiotics. Is it the location of the defect that's a big concern?

Be gentle please, I'm just curious.

 

[UWOpt2009]

FWIW, I agree with RCE. The trauma could be just opening his eyes every morning. Why can't the pt not survive on just Muro 128 5% 2x/d (qam & qhs) x 6 months. No antibiotics. Is it the location of the defect that's a big concern?

Muro ointment is another good approach for RCEs. The use of Doxy in RCEs isn't for the antibiotic action, but for its secondary effect of MMP inhibition. It's been shown that MMPs are upregulated in people with RCEs and they interfere with the new epithelium being properly laid down. The combo of doxy and lotemax apparently breaks the erosive cycle in many patients. (But, i think Muro also can do the trick!)

 

[Richard_Hom]

UWOpt2009, itek2OD

Are there any other differentials on t his case?

 

[itek2OD]

Cool. Thanks for the clarification.

 

[UWOpt2009]

Are there any other differentials on t his case?

I'd probably keep HSV in the back of my mind.

 

[Richard_Hom]

An interesting case. Jump to www.geocities.com/rchom to view the clinical case details and take a "quiz".

Richard Hom OD

 

[WoodyJI]

If the abrasion's painless, it might be some kind of genetic thing. I've read that rheumatoid arthritis can cause painless ulcers. Another painless corneal ulcer is related to leukemia. I'd start thinking about these things after ruling out infectious causes like herpes, etc.

 

[Richard_Hom]

If the abrasion's painless, it might be some kind of genetic thing. I've read that rheumatoid arthritis can cause painless ulcers. Another painless corneal ulcer is related to leukemia. I'd start thinking about these things after ruling out infectious causes like herpes, etc.

]

Thanks for your post.

1. How would you differentiate between the two.
2. Your classmates should join in.

 

[WoodyJI]

]

Thanks for your post.

1. How would you differentiate between the two.
2. Your classmates should join in.

Well, if you referred out for blood work, you'd probably get the answer. Run a CBC with a WBC differential for the leukemia. For the rheumatoid arthritis, check for RF factor, and do at least an ANA + C-RP if you're not going to do a full workup for those disease types.

 

[IndianaOD]

Rich,

Where do you post the answers to the older cases again?

 

[Richard_Hom]

On my web site. I wait a week and it is in the case index usually.