Ophtho On Call Case 3: Diagnosis & Conclusions

Diagnosis: Bacterial Corneal Ulcer

Bacterial keratitis is an ophthalmic emergency that can result in permanent corneal scarring and irreversible vision loss. It is characterized by an epithelial defect with surrounding corneal stromal infiltrate. Early diagnosis is crucial in the prevention of permanent visual loss and to reduce structural damage to the cornea. BK causes a corneal opacification which contributes to loss of vision without prompt treatment. Risk factors for bacterial keratitis include use of contact lenses, ocular surface diseases like meibomian gland dysfunction blepharitis, corneal trauma, use of immunosuppressive medications and postocular surgery (esp. Corneal graft). The most common risk factor for bacterial keratitis is contact lens wear and the incidence of developing vision threatening complications is 24%. It is not uncommon for corneal ulcers to be associated with autoimmune etiology: RA, Granulomatosis with polyangitis, Sjogren syndrom SLE, Polyarteritis nodosa, Scleroderma and others. 

 

In light of the resurgence of bacterial keratitis with contact lens wear, patients who use contacts should be counseled on safe use and the potentially harmful side effects of improper contact use. 

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Acanthamoeba can appear as dendrite

Treatment
Topical broad spectrum antibiotic therapy such a fortified Vancomycin and tobramycin drops should be used until culture results are received. Bacterial keratitis can progress very quickly with complete corneal destruction occurring within 24-48 hours. If left untreated, they can lead to corneal perforation and loss of the eye. This is especially true for immunocompromised patients with previous hx of contaminated traumatic bacterial keratitis. In cases of acanthamoeba, pool cleaner (PHMB),  pentamidine, or propamidine may be used to treat the infection. For fungal keratitis, amphotericin, voriconazole, or natamycin? may be considered. Non-healing ulcers can be treated with therapeutic penetrating keratoplasty (TPK), which involves the replacement of diseased cornea with a healthy donor corneal button. Close follow up is necessary but frequency depends on the severity of the keratitis.

will later demonstrate pallor in the affected areas.

Past trials attempted optic nerve decompression, intravitreal injections of bevacizumab, and triamcinolone with equivocal results. 

References and Additional Resources: 

1. “Retinoblastoma.” Available at: https://eyewiki.aao.org/Retinoblastoma#Differential_Diagnosis. 
2. Syed R, Ramasubramanian A,  Fekrat S, Scott IU. “A Stepwise Approach to Leukocoria.” Eyenet. July 2016. Available at: https://www.aao.org/eyenet/article/stepwise-approach-to-leukocoria.
3. Melamud A, Palekar R, Singh. “Retinoblastoma.American Family Physician. 2006;73(6):1039-1044.
4. Kaufman PL, Kim J, Berry JL. (2018). Retinoblastoma: Treatment and outcome. Payasse EA, Pappo AS, & Armsby C (Eds), UptoDate. Available at: https://www.uptodate.com/contents/retinoblastoma-treatment-and-outcome?search=retinoblastoma%20treatment&source=search_result&selectedTitle=1~82&usage_type=default&display_rank=1#H136152646.
5. Balmer A, Munier F. “Differential diagnosis of leukocoria and strabismus,  first presenting signs of retinoblastoma.” Clin Ophthalmol. 2007;1(4):431-439.
6. Correa ZM, Berry JL. “Review of Retinoblastoma.” April 2016. Available at: https://www.aao.org/disease-review/review-of-retinoblastoma.
7. Shields CL, Mashayekhi A, Cater J, et al. “Chemoreduction for Retinoblastoma: Analysis of Tumor Control and Risks for Recurrence in 457 Tumors.” Trans Am Ophthalmol Soc. 2004;102:35-45.
8. Pekacka A. The Role of Intraarterial Chemotherapy in the Management of Retinoblastoma. J Ophthalmol. 2020;2020:3638410.

Case 3 Index

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