PANCE Blueprint EENT (9%)

Corneal ulcer

Patient will present as → A 34 year old contact lense wearer who presents with severe pain, redness, worsened when eye is open (similar to corneal abrasion). The fluorescein stain demonstrates a white spot on surface of cornea.

Must be able to differentiate corneal ulcer from abrasion

  • Corneal ulcers usually represent an infection deeper in the cornea by bacteria, viruses, or fungi as a result of breakdown in the protective epithelial barrier
  • Risk factor for contact lense wearers!
  • Dendritic ulcer with fluorescein stain = Herpes Simplex Keratitis – common board review question.

All patients with corneal ulceration should be referred immediately to an ophthalmologist

Fluorescein stain is diagnostic (ulcers will often appear round “ulcerated”- like an "ulcer" vs. dendritic like herpes)

  • Corneal cultures should be obtained before starting antibiotics

Immediate referral - if immediate referral is not possible, it is reasonable to start antibiotics without delay

  • Ophthalmic antibiotics include ciprofloxacin 0.3%, ofloxacin 0.3%, gentamicin 0.3%, erythromycin 0.5%, polymyxin B/trimethoprim (Polytrim), and tobramycin 0.3%.
Corneal ulcer is perhaps the most serious risk of contact lens wear. Note the chemosis, subconjunctival hemorrhage, and corneal haze.

Corneal ulcer is perhaps the most serious risk of contact lens wear. Note the chemosis, subconjunctival hemorrhage, and corneal haze.

Question 1
A patient presents with eye pain and blurred vision. Snellen testing reveals vision of 20/200 in the affected eye and 20/20 in the unaffected eye. Fluorescein staining reveals the presence of a dendritic ulcer. Which of the following is the most likely diagnosis?
A
Viral keratitis
B
Fungal corneal ulcer
Hint:
Fungal corneal ulcers have an indolent course with intraocular infection being common but fluorescein staining is negative for a dendritic pattern.
C
Acanthamoeba keratitis
Hint:
Acanthamoeba keratitis has a waxing and waning course over several months and has no fluorescein staining in a dendritic pattern.
D
Bacterial corneal ulcer
Hint:
Bacterial corneal ulcers can progress aggressively resulting in corneal perforation. Fluorescein staining does not occur in a dendritic pattern.
Question 1 Explanation: 
Herpes Simplex virus is a common cause of dendritic ulceration noted on fluorescein staining.
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Corneal abrasion (ReelDx) (Prev Lesson)
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