Answer: The exam is most concerning for a bacterial keratitis. HSV keratitis would demonstrate a dendrite and fungal keratitis are less purulent and more indolent in nature.
Obtaining corneal scrapings for culture is important before initiating empiric antimicrobial therapy. Gram stain and giemsa stain of the corneal smear should also be performed to determine if the ulcer is bacterial or fungal. Contact lens cases and solutions can also be cultured if available.
Smears and cultures are indicated in the following cases of bacterial keratitis:
- Sight-threatening or severe keratitis
- Large infiltrates
- Central infiltrates
- No response to broad spectrum antibiotics
- Atypical clinical features indicative of fungus or acanthamoeba
- Multiple infiltrates in different location of the cornea
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