Ophtho On Call Case 3: Additional History & Physical Exam

Ophtho On Call Case 3 Index

Additional History: 

Upon further questioning, she admits to occasionally falling asleep in her contacts after long nights of studying. She wears “Daily” contact lenses that she usually throws away but reports reusing her last pair and storing the contacts in tap water overnight until her new contacts arrived. There was no history swimming with the contact lenses and she denies allergies, eye trauma or use of any medications.

Physical Exam: 

General appearance: Well-appearing and in no apparent distress 
Vitals: Temp: 36C, BP: 112/70, HR: 68, RR 16
Best Corrected Visual Acuity (BCVA): OD 20/20, OS 20/50
Pupils: Pupils equal and reactive to light OU, no rAPD OU
EOM: full OU 

Confrontation Visual Fields (CVF): Full OU
Intraocular pressures (Tonopen in ED): OD 15 mmHg, OS 22 mmHg

External examination of the right eye is within normal limits. Below is an external image of the left eye:

corneal ulcer KH

Above Image Credit: Kyle Hirabayashi, MD 

How would you describe the image above?
Corneal epithelial defect with surrounding infiltrate
Corneal abrasion with fluroescein uptake
Corneal scar
Corneal edema
 

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Ophtho On Call Case 3 Index
Ophtho On Call Case 3: Introduction