Wiler, Jennifer L. MD, MBA
Dr. Wiler is an assistant professor of emergency medicine and the vice chair of the department of emergency medicine at the University of Colorado School of Medicine. Read her past columns at http://bit.ly/WilerConsult.
A 45-year-old woman presents after waking with left eye pain and photophobia. She denies an acute event, but complains of a tearing and a foreign body sensation. She wears daily contact lenses, which she removed the night before.
Here is what you see on fluorescence staining. What is the diagnosis, and how would you treat this condition?
Diagnosis: Corneal Ulcer
Corneal ulcers are considered an ophthalmologic emergency in the ED because these conditions can result in corneal melting, preformation, and permanent vision loss.
Corneal ulcers can be caused by infectious pathogens, trauma such as direct blunt force, dry eyes, an inability to close the eyelid (Bell's palsy), and conditions causing decreased sensation of the cornea. The etiology of ulcers that develop in patients who wear contact lenses are typically bacterial such as coagulase-negative staphylococci, Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pneumoniae, and Enterobacteriaceae.
Corneal ulcers also can be caused by viral etiologies, such as varicella and herpes, fungal ones such as Fusarium, and parasitic infections amoeba. (Cornea 2013;32:982.)
An intact cornea can be disrupted, and that typically occurs after a violation, often a micro disruption, of the corneal tissue that then becomes infected. Autoimmune diseases, including peripheral ulcerative keratitis, are also a known etiology of severe corneal ulceration. Patients with vitamin A deficiency and immunocompromise are also at increased risk of developing this condition, as are overnight contact lens wearers and those with inadequate lens hygiene. It is estimated that infections occur in approximately two to four per 10,000 standard soft contact lenses users and 10 to 20 per 10,000 extended-wear users. (Arch Ophthalmol 2010;128:1022; Clin Exp Optom 2005;88:232.)
Patients with corneal ulcers may present with eye discharge, pain, eyelid swelling, foreign body sensation, photophobia, or blurred vision. As with any patient with an ocular complaint, a complete physical examination of the globe should be performed, including a slit lamp examination. The differential diagnosis corneal ulcer is extensive and includes any condition that causes a red painful eye.
Diagnosing a corneal ulcer tends to be clinical. Ulcers appear to be focal white opacities in the corneal stroma, which stains with topical fluorescein. Corneal cultures and scrapings may be obtained, though they are not typically considered routine, but they may be performed for ulcers not responsive to treatment. This should be done by an ophthalmologist. Immediate evaluation and treatment of a corneal ulcer by an ophthalmologist is indicated because of the risk of globe rupture.
Treating this condition depends on the suspected etiology, but therapy includes broad-spectrum topical antibiotics for suspected bacterial infections and cycloplegic medications to prevent ciliary muscle spasm and associated pain. Using topical steroids is controversial, but topical analgesics in the ED can be helpful to perform an adequate examination. A patient should never be discharged from the ED with these medications because they can prevent recognition of progressing disease. Patients with corneal ulcers as a result of contact lens use should stop wearing contacts until the condition completely heals.
The known complications of corneal ulceration include globe perforation, cataract formation, anterior or posterior synechiae, glaucoma, and corneal scarring. (Wills Eye Manual, Philadelphia: Lippincott Williams & Wilkins; 2012.)
This patient was seen by an ophthalmologist in the ED, and he started the patient on topical antibiotic therapy and cycloplegic medications. The patient was noted to have achieved appropriate healing on her return visit to the eye clinic.
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