A 13-year-old boy is brought to clinic by his parents due to copious, purulent discharge from his right eye. The patient's eye was crusted shut this morning. His father was able to open the eye by wiping it with a damp washcloth. The patient went to school but was sent home by the school nurse. He has not had ocular pain, visual changes, or fever. He lives at home with his parents and older sister, none of whom have similar symptoms. The patient has mild myopia and wears contact lenses. He takes loratadine daily for seasonal allergies. Vital signs are within normal limits. Examination shows conjunctival erythema and yellow exudate in the right eye. The conjunctiva of the left eye is also erythematous, but there are no secretions. Visual acuity testing with the patient's contacts removed shows 20/80 vision in both eyes, consistent with his well-child examination at age 12. The parents administer the treatment as prescribed. After 2 days of treatment, the initial symptoms have not improved, and the child now says, "The light really bothers me, and it feels like there is something really painful in my eye." Which of the following is the most appropriate next step in treatment?

Question

A 13-year-old boy is brought to clinic by his parents due to copious, purulent discharge from his right eye.  The patient's eye was crusted shut this morning.  His father was able to open the eye by wiping it with a damp washcloth.  The patient went to school but was sent home by the school nurse.  He has not had ocular pain, visual changes, or fever.  He lives at home with his parents and older sister, none of whom have similar symptoms.  The patient has mild myopia and wears contact lenses.  He takes loratadine daily for seasonal allergies.  Vital signs are within normal limits.  Examination shows conjunctival erythema and yellow exudate in the right eye.  The conjunctiva of the left eye is also erythematous, but there are no secretions.  Visual acuity testing with the patient's contacts removed shows 20/80 vision in both eyes, consistent with his well-child examination at age 12. The parents administer the treatment as prescribed.  After 2 days of treatment, the initial symptoms have not improved, and the child now says, "The light really bothers me, and it feels like there is something really painful in my eye."  Which of the following is the most appropriate next step in treatment?

Quizplus · Accepted Answer

Explanation: This patient with conjunctivitis has now developed signs of keratitis, which presents with photophobia, blurred or impaired vision, and a foreign body sensation with difficulty opening the affected eye. When keratitis is suspected, the patient should be seen urgently by an ophthalmologist to confirm the diagnosis and begin treatment. The diagnosis of keratitis is made by slit-lamp examination showing corneal ulceration. The epithelial injury is readily visible with fluorescein. Cultures of corneal scraping should be obtained to help guide definitive antibiotic therapy. While those cultures are processing, empiric therapy should be changed to topical, combination antibiotic therapy that has broad-spectrum activity against gram-positive and gram-negative organisms, including Pseudomonas. Keratitis can cause scarring or ulceration of the cornea and subsequent blindness if not aggressively treated. (Choices A and D) Intravenous or oral fluoroquinolone therapy does not provide any additional drug delivery to the cornea or conjunctiva and does not provide sufficient coverage against gram-positive organisms. However, intravenous therapy may be indicated for patients whose compliance with oral or topical therapy cannot be assured. (Choice C) Antibiotic therapy is critical in the management of keratitis and should not be discontinued. In addition, irrigation of the eye is likely to be painful if the corneal epithelium is disrupted. (Choice E) Polymyxin-trimethoprim drops have activity against gram-positive organisms and some gram-negative organisms (eg, Haemophilus influenzae), and could serve as prophylaxis for the ulcer. However, Pseudomonas is often resistant to polymyxin, making it a poor choice for this patient. Educational objective: Management of suspected keratitis, which can cause blindness if untreated, includes urgent referral to an ophthalmologist. References: Fluoroquinolones or fortified antibiotics for treating bacterial keratitis: systematic review and meta-analysis of comparative studies. (http://www.ncbi.nlm.nih.gov/pubmed/23217502)

A 13-Year-Old Boy Is Brought to Clinic by His Parents