Paul presents with on painful red eye with mild loss of vision on a background of contact lens use. He is adamant that he replaces them regularly and keeps them clean with disinfectant.

What is the MOST LIKELY primary diagnosis?

1. Pseudomonas Aureginosa Keratitis

What are the differentials for this presentation? (6)

1. Bacterial Keratitis
   
2. Gonococcal Keratitis
   
3. Herpes simplex Keratitis
   
4. Fungal Keratitis

What is the number one risk factor for this condition? (1)

1. Unilateral painful red eye
   
2. Corneal epithelial defect on fluorescein staining
   
3. Reduced VA
   
4. Oedema.
   
5. Greenish yellow or blue-green discharge
   
6. Surrounding cornea has ground glass appearance
   
7. Ring abscess without epithelial defect
   
8. Rapid progression to marked oedema

What are the KEY FEATURES OF EXAMINATION in Pneumooccal Bacterial keratitis? (8)

1. Unilateral painful red eye
   
2. Corneal epithelial defect on fluorescein staining
   
3. Reduced VA
   
4. Oedema.
   
5. Leveled hypopyon in most
   
6. Advancing border (creeping edge) with dense infiltrate
   
7. Undermined edges on border
   
8. Trailing edge may she signs of healing

What are the KEY FEATURES OF EXAMINATION in Gonococcal Keratitis (5)

1. Unilateral painful red eye
   
2. Corneal epithelial defect on fluorescein staining
   
3. Reduced VA
   
4. Oedema.
   
5. Severe Lid Oedema
   
6. Purulent Discharge

What are the KEY FEATURES OF EXAMINATION in Viral Keratitis (6)

1. Unilateral painful red eye
   
2. Unilateral dendritic ulcer seen on fluorescein
   
3. Reduced VA
   
4. Oedema
   
5. Rash
   
6. fever
   
7. URTI

What are the KEY FEATURES OF EXAMINATION in Fungal Keratitis (8)

1. Unilateral painful red eye
2. Corneal epithelial defect on fluorescein staining
3. Reduced VA
4. Oedema.
5. Central corneal involvement
6. Raised creamy surface
7. Feathery edges – mimicking dendritic ulcer
8. Satellite lesions
9. Immune ring – central lesion, surrounded by opaque ring with clear zone in between
10. Unlevelled hypopyon
11. If pigmented, the ulcer will appear as raised leathery down lace
12. minimal lid edema, even with severe case

What are the MOST IMPORTANT IMMEDATE MANAGEMENT steps in managing this condition? (4)

1. Immediate referral to ophthalmologist
2. Topical fluoroquinolone – (ciprofloxacin eye drops)
3. Patients with a contact lens–related abrasion should not be patched because of the risk of bacterial superinfection.
4. Contact lenses should be discarded, and new ones should not be worn until the abrasion is healed and symptoms are resolved.
5. To avoid future episodes, physicians should ensure that lenses fit properly, and instruct patients to practice proper lens hygiene and avoid extended-wear lenses.

What are the complications that can arise from this presentation? (3)

1. Cornea scarring
   
2. Leading to Visual Acuity decline
   
3. Irregular astigmatism
   
4. Driving and occupational implications
   
5. Corneal perforation and loss of eye

What are the side effects of topical corticosteroids? (4)

1. Decrease rate of epithelial healing
   
2. Inhibit host immune response
   
3. Inhibit collagen synthesis lead to corneal melt
   
4. Raise intraocular pressure

References

1. patient.info
2. Murtaghs
3. Colour Atlas of Family Medicine
4. Dynamed