A 42-year-old man comes to the emergency department due to a week of eye pain and blurry vision. Initially, he developed mild red eye and irritation, which he attempted to manage with artificial tear drops. The patient works as a commercial fisherman and had assumed his symptoms were due to frequent sun and water exposure. However, over the past few days, his eye pain has worsened, and he can "barely see" out of his left eye. He has no medical history but has a family history of hypertension and diabetes. Temperature is 37.2 C (99.1 F). Blood pressure is 128/82 mm Hg, pulse is 70/min, and respirations are 11/min. There is copious clear drainage from the left eye, and a large ulceration is overlying the cornea; the right eye appears unremarkable. Minimal sensation of the left cornea is noted during esthesiometry testing. With fluorescein application, additional shallow linear, branched ulcerations are visualized along the margins of the central defect of the affected eye. Routine Gram stain of the bacterial culture shows numerous white blood cells but no organisms. Which of the following should be started immediately in this patient?

Question

A 42-year-old man comes to the emergency department due to a week of eye pain and blurry vision.  Initially, he developed mild red eye and irritation, which he attempted to manage with artificial tear drops.  The patient works as a commercial fisherman and had assumed his symptoms were due to frequent sun and water exposure.  However, over the past few days, his eye pain has worsened, and he can "barely see" out of his left eye.  He has no medical history but has a family history of hypertension and diabetes.  Temperature is 37.2 C (99.1 F).  Blood pressure is 128/82 mm Hg, pulse is 70/min, and respirations are 11/min.  There is copious clear drainage from the left eye, and a large ulceration is overlying the cornea; the right eye appears unremarkable.  Minimal sensation of the left cornea is noted during esthesiometry testing.  With fluorescein application, additional shallow linear, branched ulcerations are visualized along the margins of the central defect of the affected eye.  Routine Gram stain of the bacterial culture shows numerous white blood cells but no organisms.  Which of the following should be started immediately in this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c010_0b65_8f63_63266347cedb_MD0005_00 This patient with eye pain/redness, blurred vision, and a corneal ulceration most likely has infectious keratitis, or inflammation of the cornea. This condition can be caused by bacteria, viruses, or fungi and can lead to permanent visual impairment and blindness if untreated. Prompt antimicrobial therapy is warranted for infectious keratitis, and ophthalmologic findings can often differentiate various pathogens to guide management decisions: Dendritic ulcerations: Branched linear lesions, as seen here, are characteristic of herpes simplex virus (HSV) keratitis, the most likely diagnosis in this case. Recurrent episodes are often precipitated by excessive sun exposure, as in this case, and clear watery drainage is typical. Decreased corneal sensation is a classic finding of HSV keratitis and is due to viral infection of the V1 branch of the trigeminal nerve (CN V). Untreated infection is the most common cause of corneal blindness in resource-rich countries, and suspected cases should be treated with prompt initiation of topical or oral antiviral therapy (eg, acyclovir, valacyclovir). Central round infiltrate: This lesion is typically seen in bacterial keratitis, and a causative organism (eg, Staphylococcus aureus) would be expected on Gram stain, not seen here. Patients who use contact lenses improperly (eg, infrequent cleaning) are at highest risk, and symptoms usually include mucopurulent, not clear, discharge. Management is topical antibiotic therapy (Choice C). Multiple ulcers with feathery margins: These findings are typical of fungal (eg, Candida) keratitis. This diagnosis is rare and typically presents in immunocompromised patients after corneal trauma involving contaminated soil. In addition, disease progression is usually more gradual compared to bacterial and viral keratitis. Treatment is with topical or oral antifungals (Choice A). (Choice B) Systemic steroids can be used for autoimmune keratitis, which is characterized by corneal ulceration but not dendritic branching. In addition, this condition is typically associated with a systemic autoimmune disease (eg, rheumatoid arthritis), not seen here. (Choice E) Topical prostaglandins are a treatment for glaucoma, which can present acutely with red eye, pain, and vision loss, but corneal ulceration would not be present. Educational objective: Infectious keratitis presents with eye pain/redness, blurry vision, and corneal ulcerations. Herpes simplex virus keratitis should be suspected in patients with watery discharge, decreased corneal sensation, and dendritic ulcerations. Management is topical or oral antiviral therapy (eg, acyclovir). References: Herpes simplex keratitis revisited. (http://www.ncbi.nlm.nih.gov/pubmed/34320112)

A 42-Year-Old Man Comes to the Emergency Department Due to a Week