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