Grand Rounds - Red, Painful Left Eye

[Richard_Hom]

Dear 3rd Year, 4th Year, and Residents in Optometry:

HPI:
A 41 year old woman presents to the clinic from the ED (2d visit to the ER and the last patient on Friday) with the following concerns:
1. Red, irritated, angry, tearful and photophobic left eye
2. Pain relief from hurting left eye

The patient has worn soft contact lenses for 20 years. On 16 JUL, the
patient presented to an optometrist's office complaining of photophobia,
FBS, and redness in the left eye after removal of her soft lenses the night
before. She states that she did not try to insert the lenses that morning.
The optometrist diagnosed corneal ulcer and started her on Vigamox 1gtt, OS, QID.

Subsequently, she presented to the ED on 21 JUL complaining of the same. Her symptoms are worse. The ED gave her Ciloxan QID, Acular BID, Vicodin 1 tab q4hrs. She saw an ophthalmologist that same day at this clinic and was started on Zymar q1hr while awake.

Today, she is no better and feels worse. Evidently, she never took the Zymar
for reasons unknown.

PE:
BVA in this eye is 20/50.

The slit lamp shows a 2mm ulcer just above the pupillary border and a large
(4mm x 2mm) white spot midway between the pupillary border and the limbus
with the long axis vertically-oriented. There is a slight flare in the AC,
but no cells. The conjunctival is watery but no discharge. THere is trace
papillary/follicular hypertrophy.

A photograph is attached. The white cigar-shaped white spot is at 10 o'clock. Unfortunately, the 2mm ulcer at the superior pupillary border is not visible in this photo. The "lolliop"-type image at 6:00 is an artifact of the camera flash.

Questions:
1. What is your tentative diagnosis?
2. What is the differential?
3. Additional testing?

PLAN: Which plan would you do?:

1. Zymar q15mins x 4 hrs; q30mins x 4 hrs; QID x 4 days thereafter
2. Zymar QID from the begining
3. Fortified antibiotics such as ceftriaxone at 35mg/ml and Tobramycin at
15mg/ml q 1r while awake for 2 days then QID thereafter
4. Vigamox QID
5. Viagmox q15 mins x 4 hrs; q40mins x 4 hrs; QID x 4 days thereafter
5. Ciloxin or Ocuflox q15mins x 4 hrs; q30mins x 4hrs; QID x 4 days
6. Your own regimen? Please suggest.

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[optcom]

1. not bacterial infection.
2. acanthamoeba?(cl wear), viral, fungal?
3. lid inversion, culture, #3 will be my choice.

 

[Richard_Hom]

1. not bacterial infection.
2. acanthamoeba?(cl wear), viral, fungal?
3. lid inversion, culture, #3 will be my choice.

Thanks optcom,

1. Why not bacterial?
2. How would you differentiate viral, from fungal, from acanthamoeba?
3. Why lid eversion?

Thanks,

 

[optcom]

1. px is on antibiotics for a while, and it's no better. So bacterial infection is less likely, but not impossible.
2. preauricular node enlargement?- viral likely,
home-made solution, swimming in the pool with cl on?-acanthamoeba likely.
3. trapped FB under the lid?

 

[Andrew_Doan]

In addition to the above, consider collagen vascular diseases, rheumatoid diseases, lupus, Mooren's ulcer, auto-immune, map-dot fingerprint, and resistant microbacterial. This may be infectious still because Zymar and other routinely used topicals may not be enough.

She needs standard cultures and confocal microscopy (to detect acanthamoeba), and then started on:

Fortified antibiotics such as Vancomycin and Tobramycin Q15Min x 4-6 doses, then Q1Hour during the day and night. I'd see her back daily.

See her back in 1 day and determine if she is responding. If not, then continue the same regimen. I would not decrease this regimen until she's received ~week course to determine response.

If no response, then draw blood for ESR, CRP, rheumatoid factor, ANA, and send patient for corneal biopsy.

 

[ituryu]

Well I guess I am late with my reply , but I haven't been online for a while .
My tentative Dx would be Bacterial cojunctivitis with corneal involvement most likely caused by Neisseria sp. and Chlamydial conjunctivitis , I will have to say that the case Hx was inadequate !
Differential Dx would be via culture and sensitivity test using Gram's and / or Giemsa staining technique .
The pain is indicative of corneal involvement , hte photophobia is indicative of iris involvement due to diffusion of bacterial toxin into the ant. chamber , thus toxic iritis as revealed by SLX since there is a flare ,but no inflammatory cell observed , no pannus and a Hx of trachoma .
My add. testing would be hypersensitivity rxn to CL solution as the watery discharge suggest allergic rxn.
My plan trx.
Ciloxan q15min 4hrs ,
Ciloxan q30min 4hrs
Ciloxan qid 4/7 thereafter
polysporin nocte 5/7 ,
Tabs . Ceftriaxone 1g bid 5/7 .
The irritated eye is a sign of poor tearing , stop CL wear until trx is completed , and re-eveluate Cl wear.

 

[Andrew_Doan]

Well I guess I am late with my reply , but I haven't been online for a while .
My tentative Dx would be Bacterial cojunctivitis with corneal involvement most likely caused by Neisseria sp. and Chlamydial conjunctivitis , I will have to say that the case Hx was inadequate !
Differential Dx would be via culture and sensitivity test using Gram's and / or Giemsa staining technique .
The pain is indicative of corneal involvement , hte photophobia is indicative of iris involvement due to diffusion of bacterial toxin into the ant. chamber , thus toxic iritis as revealed by SLX since there is a flare ,but no inflammatory cell observed , no pannus and a Hx of trachoma .
My add. testing would be hypersensitivity rxn to CL solution as the watery discharge suggest allergic rxn.
My plan trx.
Ciloxan q15min 4hrs ,
Ciloxan q30min 4hrs
Ciloxan qid 4/7 thereafter
polysporin nocte 5/7 ,
Tabs . Ceftriaxone 1g bid 5/7 .
The irritated eye is a sign of poor tearing , stop CL wear until trx is completed , and re-eveluate Cl wear.

Chlamydial and N. gonnorrhea are not the most common organisms related to contact lens use. Also, these are both purulent conjunctivitis and from the photos, we don't see purulence. In addition, this is too acute for these organisms to cause a conjunctivitis and corneal ucler.

The tapering of Ciloxan drops should be determined by the response of the patient. I don't generally recommend writing a prescription for a taper after seeing the patient only once. For instance, if you start on Q1Hour drops and the patient gets better, then jump to QID dosing (i.e. every 6 hours) after 4 hours which may not be adequate and the infection may worsen. You'll be stuck with thinking that the medication did not work when the patient needed more frequent dosing.

Why Polysporin too? This doesn't add to the coverage already provided by Ciloxan. Sulfa allergies are common, and you may inadvertantly make the condition worse with an allergic reaction.

Ceftriaxone is an injectable medication and does not come in pill form. If you're thinking that you're treating a systemic illness due to chlamydia/gonorrhea co-infection, then BOTH Ceftriaxone IM AND Azithromycin or doxycycline or tetracycline are indicated.

I think the treatment of systemic illness is better done by MDs, particularly if you suspect a STD.