A 32-year-old man complains of right eye pain and discharge. His symptoms began acutely on awakening in the morning. He uses extended-wear contact lenses and has had difficulty removing the lenses for the last week. His past medical history is significant for obesity, chronic back pain, asthma, and acid reflux disease. On examination, thick, globular yellow discharge is present at the medial eye corner and on the lid margins. The cornea is edematous, hazy, and ulcerated and there is extensive scleral injection, as shown in the image. What is the most likely diagnosis in this patient?

Question

A 32-year-old man complains of right eye pain and discharge.  His symptoms began acutely on awakening in the morning.  He uses extended-wear contact lenses and has had difficulty removing the lenses for the last week.  His past medical history is significant for obesity, chronic back pain, asthma, and acid reflux disease.  On examination, thick, globular yellow discharge is present at the medial eye corner and on the lid margins.  The cornea is edematous, hazy, and ulcerated and there is extensive scleral injection, as shown in the image.  What is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This patient with a painful, red eye and opacification and ulceration of the cornea has typical features of contact lens-associated keratitis. Most cases are due to Gram-negative organisms such as Pseudomonas and Serratia, but can also be due to Gram-positive organisms as well as certain fungi and amoebas. Contact lens-associated keratitis is a medical emergency and can lead to corneal perforation, scarring, and permanent vision loss if not addressed promptly. In addition to removal and discarding of the contact lens, most patients require topical broad-spectrum antibiotics. (Choice A) Acute angle-closure glaucoma, usually seen in older patients (age >40), may also present with a red, painful eye and blurred vision. Corneal opacification can be present, but ulceration is not typical. The pupil is fixed and mid-dilated. Extraocular symptoms such as headache and nausea are common. Acute angle-closure glaucoma (Choice B) Anterior uveitis (iritis) is inflammation of the anterior uveal tract, especially the iris. Patients often have associated conjunctival inflammation adjacent to the cornea, but the cornea itself is usually spared. Anterior uveitis (Choice C) Episcleritis is a common cause of red eye and is distinguished by its localized or patchy distribution and generally mild associated pain and discharge. It may occur in association with rheumatoid arthritis and other autoimmune disorders, but many cases are idiopathic. Episcleritis is usually self-limited and does not affect vision or involve the cornea. Episcleritis (Choice D) Patients using extended-wear contact lenses are at risk for both bacterial conjunctivitis and keratitis. Involvement of the cornea indicates keratitis, and the cornea is generally spared in uncomplicated conjunctivitis. The infection in this patient is likely due to Pseudomonas. (Choice F) Subconjunctival hemorrhage is usually caused by local trauma or Valsalva maneuver (eg, coughing, sneezing, vomiting). Patients will have a well-demarcated patch of extravasated blood beneath the conjunctiva. Most cases are benign and require no specific therapy. Subconjunctival hemorrhage (Choice G) Viral conjunctivitis ("pink eye") is usually preceded by typical nasopharyngeal symptoms. Corneal involvement is uncommon. Viral conjunctivitis is most common in the late summer and fall and may occur in clusters or small epidemics. Educational objective: Contact lens-associated infectious keratitis is a medical emergency that causes a painful, red eye and opacification and ulceration of the cornea. Most cases are due to Gram-negative organisms but can also be due to Gram-positive organisms as well as certain fungi and amoebas. Most cases require topical broad-spectrum antibiotics. References: Infectious keratitis. (http://www.ncbi.nlm.nih.gov/pubmed/17496570)

A 32-Year-Old Man Complains of Right Eye Pain and Discharge