Ophtho On Call Case 3: Case Continued…

Ophtho On Call Case 3 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
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