Case 6: Follow up Physical Exam Continued…

Case 6 Index

Answer: It’s important to perform flourescein staining and examination of the cornea under cobalt blue light. Flourescein staining is particularly important given the history of sleeping in contact lenses. A corneal abrasion or ulcer needs to be ruled out and flourescein will highlight areas of corneal epithelial defects. Both of these corneal injuries can be extremely painful. Below is an example of a corneal abrasion stained with flourescein both with and without cobalt blue light. 

corneal abrasion with cobalt blueAbove image credit

Herpetic keratitis can also present with red eye and decreased vision and fluorescein would highlight a dendrite. This is an example of a herpetic dendrite illuminated by fluorescein under cobalt blue light.

herpetic dendriteAbove image credit

Back to our patient…

Flourescein staining of our patient’s cornea is within normal limits (no staining, no abrasion, ulcer, or dendrite).

On fundoscopic exam with the panoptic, you see this:

PDR flickrAbove image credit

You also notice on palpation of the eyes, with the eyelids closed, that the right eye feels extremely firm

What could the “firmness” indicate? Select one answer:
Elevated Intraocular Pressure

Here’s one more consideration before we narrow the differential:

What is the acuity of this presentation?
Emergent, refer to ER immediately!
Nonurgent, can see ophthlamology in a few weeks

Considering these factors, it’s time to hone in on a diagnosis. 

What’s the most likely diagnosis? Select one answer before moving on. 
Non-proliferative diabetic retinopathy
Herpetic keratitis
Retinal detachment
Central retinal artery occlusion
Acute angle closure glaucoma
Central retinal vein occlusion
Neovascular glaucoma
Corneal ulcer

Click here to move on!

Case 6 Index

Case 6: Introduction
Case 6: Physical Exam
Case 6: Ophtho visit
Case 6: 2 years later…
Case 6: Follow up physical exam