Ophthalmology
This was previously featured in an exam
This was previously featured in an exam
Question 145 of 180
A 35 year old woman presents to ED complaining of a severely painful burning eye with photophobia. The eye is red and watering. On examination, the above abnormality is seen. What is the treatment of choice in this patient?
Answer:
The fluorescein staining shows the typical linear branching corneal ulcer (dendritic ulcer) seen in herpes simplex epithelial keratitis. First line treatment is with topical ganciclovir or aciclovir.Infective Keratitis
Ophthalmology
Last Updated: 10th January 2023
Bacteria, fungi, protozoa, and viruses can penetrate the body's defence mechanisms and invade the cornea. A key underlying predisposing factor for bacterial, fungal, Acanthamoeba, and viral keratitis is a compromised corneal epithelium.
Risk Factors
- Corneal trauma
- Contact lens wear
- Corneal abrasion/erosion
- Corneal exposure from poor lid function
- Foreign body (particularly vegetable matter)
- Previous eye surgery
- Severe dry eyes
- Trichiasis
- Hereditary corneal dystrophies
- Blepharitis and conjunctivitis
- Immunosuppression
Causes
- Bacteria
- Pseudomonas aeruginosa
- Staphylococcus aureus
- Staphylococcus epidermidis
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
- Viruses
- Herpes simplex
- Varicella/Herpes zoster
- Fungi
- Aspergillus and Fusarium species
- Candida albicans
- Protozoa
- Acanthamoeba species
Clinical Features
- Symptoms
- Eye pain
- Redness
- Photophobia
- Lacrimation
- Discharge
- Lid oedema
- Reduced visual acuity
- Signs
- Corneal infiltrate (presence of pathogens and inflammatory cells in the corneal stroma causes oedema and opacification of the normally transparent cornea)
- Corneal ulcer (a corneal infiltrate with an overlying epithelial defect is termed a corneal ulcer)
- Corneal vesicles (may be seen in herpetic keratitis)
- Dendritic ulcer (in HSV epithelial keratitis)
- This classic herpetic lesion consists of a linear branching corneal ulcer
Management
- Refer urgently to ophthalmology
- Corneal scrapings should be sent for cultures and sensitivity prior to initiating treatment
- General management
- Contact lens use should be discontinued while the eye is inflamed
- Oral analgesics and other pain medicine should be given as needed
- A topical cycloplegic (pupil-dilating agent) should be used in the presence of an anterior chamber reaction and photophobia
- An eye shield should be placed over eyes when considerable corneal thinning is present
- Bacterial infection
- Unless specific historical or clinical evidence suggests otherwise, microbial keratitis should be assumed to be bacterial; empiric treatment consists of topical antibacterials
- Topical corticosteroids should usually be added as soon as the epithelial defect closes and the infiltrate appears to be responding well to the antibiotic treatment.
- Even in non-bacterial infectious keratitis, epithelial defects should prompt the use of broad-spectrum topical antibacterials for prophylaxis
- Herpetic infection
- Topical antiviral drug treatment for epithelial keratitis
- Oral antiviral and topical corticosteroid drug treatment for stromal keratitis
Complications
- Corneal perforation
- Endophthalmitis
- Corneal scarring
- Cataract
- Glaucoma
- Secondary infection
- Permanent visual impairment
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
