Ophtho On Call Case 3: Case Continued…

Ophtho On Call Case 5 Index

Answer: The image shows a corneal epithelial defect with surrounding corneal haze suggestive of a corneal infiltrate. 

Slit lamp and dilated fundus exam demonstrates the following: 

External ocular exam:
Eyelids: OD flat OU, OS 1+left upper eyelid edema with erythema
Conjunctiva: OD white and quiet, OS 2+conjunctival injection most prominent temporally, with mild chemosis
Cornea: OD clear, OS 4×4 mm central stromal infiltrate with overlying epithelial defect
Anterior Chamber: OD deep and quiet, OS 4+cell and flare with 0.5 mm hypopyon
Iris: Round and reactive OU
Lens: Clear OU

Dilated fundus exam:
Vitreous: Clear OU, no vitritis OS
Optic nerves: C/D 0.3 OU, sharp and pink OU
Macula: Flat OU
Vessels Normal OU
Periphery: flat 360, no breaks

 

What’s at the top of your differential now? Pick 1 before moving on.
Bacterial keratitis 
Fungal keratitis 
 
HSV keratitis
Corneal abrasion
Corneal scar 
Corneal graft rejection 

What would you like to obtain next? Click all that apply
B-scan
Corneal scrapings for culture
 
CT orbits
MRI orbits
 
 

Click here to move on!

Ophtho On Call Case 3 Index
Ophtho On Call Case 3: Introduction
Ophtho On Call Case 3: Additional History & Physical Exam