Pain and Decreased Vision in a Teenager
A 14-year-old girl presents with pain and decreased vision in the right eye of 1 day's duration. She is now unable to open the eye because of extreme pain and photosensitivity. The affected eye is tearing profusely and is producing mucoid discharge. The patient removed her contact lenses and put contact lens wetting solution in the eye, but the symptoms persisted. She put her contact lenses back in, which made the eye feel slightly better. However, by evening, her eyesight was very blurred and the eye was light sensitive, and she again removed her contact lenses. Upon waking this morning, she was unable to open the right eye because of extreme pain and light sensitivity and had very poor vision.
Her medical history is significant for myopia, which was detected at age 8 years. She started wearing soft, disposable contact lenses at the age of 12 years. She now wears these contact lenses exclusively and does not own a pair of glasses. She states that she frequently sleeps while wearing her contact lenses and showers and swims with them on. When she removes her contact lenses, she stores them in a cleaning solution overnight. Although the contact lenses are intended to be disposed of every 2 weeks, she frequently uses them longer. She has had one to two episodes of "pink eye" during the past 2 years but did not seek medical attention, and the condition resolved spontaneously in a day or two. She is up to date with her immunizations. A review of systems is negative. She currently is taking no medications.
Upon examination, the patient appears alert and in obvious distress. She is cupping her right eye with her hand and is tearing profusely. Testing the vision in the affected eye is difficult because of the patient's discomfort. She is only able to count fingers with the right eye and has 20/20 vision in the left eye with use of her contact lens. A significant amount of mucopurulent discharge from the right eye is noted. The right upper lid is swollen and mildly erythematous. Upon opening the eye, the conjunctiva is noted to be very erythematous with mild chemosis. The cornea reveals a white, soupy lesion centrally with indistinct edges measuring approximately 5 by 5 mm (Figure). Fluorescein staining reveals an epithelial defect overlying the lesion. The anterior chamber reveals layered pus (hypopyon) inferiorly that measured 2.5 mm in height. The iris and lens are not well visualized but appear to be grossly normal. Examination of the fundus is not possible because of the infiltrate overlying the pupil and the severe photophobia. The left eye is completely normal, and findings of the systemic examination are unremarkable.
(Enlarge Image)
Figure.
White, soupy infiltrate on the cornea with a layered hypopyon in the anterior chamber inferiorly. This figure appears in color online at www.jpedhc.org.
The patient is sent to an ophthalmologist immediately for further management. The ophthalmologist diagnoses a bacterial corneal ulcer. A gram stain of scrapings from the ulcer reveals numerous white blood cells and gram-negative rods. Topical antibiotics (fortified tobramycin and moxifloxacin) and cycloplegic eye drops are prescribed and the patient begins to use them immediately. The cultures eventually grow Pseudomonas species. The patient responds to the treatment and the corneal ulcer heals during the next 2 weeks. However, she is left with a central corneal scar and very poor vision that is not correctable with glasses. She currently is considering a corneal transplant to improve her vision.
Introduction
A 14-year-old girl presents with pain and decreased vision in the right eye of 1 day's duration. She is now unable to open the eye because of extreme pain and photosensitivity. The affected eye is tearing profusely and is producing mucoid discharge. The patient removed her contact lenses and put contact lens wetting solution in the eye, but the symptoms persisted. She put her contact lenses back in, which made the eye feel slightly better. However, by evening, her eyesight was very blurred and the eye was light sensitive, and she again removed her contact lenses. Upon waking this morning, she was unable to open the right eye because of extreme pain and light sensitivity and had very poor vision.
Her medical history is significant for myopia, which was detected at age 8 years. She started wearing soft, disposable contact lenses at the age of 12 years. She now wears these contact lenses exclusively and does not own a pair of glasses. She states that she frequently sleeps while wearing her contact lenses and showers and swims with them on. When she removes her contact lenses, she stores them in a cleaning solution overnight. Although the contact lenses are intended to be disposed of every 2 weeks, she frequently uses them longer. She has had one to two episodes of "pink eye" during the past 2 years but did not seek medical attention, and the condition resolved spontaneously in a day or two. She is up to date with her immunizations. A review of systems is negative. She currently is taking no medications.
Upon examination, the patient appears alert and in obvious distress. She is cupping her right eye with her hand and is tearing profusely. Testing the vision in the affected eye is difficult because of the patient's discomfort. She is only able to count fingers with the right eye and has 20/20 vision in the left eye with use of her contact lens. A significant amount of mucopurulent discharge from the right eye is noted. The right upper lid is swollen and mildly erythematous. Upon opening the eye, the conjunctiva is noted to be very erythematous with mild chemosis. The cornea reveals a white, soupy lesion centrally with indistinct edges measuring approximately 5 by 5 mm (Figure). Fluorescein staining reveals an epithelial defect overlying the lesion. The anterior chamber reveals layered pus (hypopyon) inferiorly that measured 2.5 mm in height. The iris and lens are not well visualized but appear to be grossly normal. Examination of the fundus is not possible because of the infiltrate overlying the pupil and the severe photophobia. The left eye is completely normal, and findings of the systemic examination are unremarkable.
(Enlarge Image)
Figure.
White, soupy infiltrate on the cornea with a layered hypopyon in the anterior chamber inferiorly. This figure appears in color online at www.jpedhc.org.
The patient is sent to an ophthalmologist immediately for further management. The ophthalmologist diagnoses a bacterial corneal ulcer. A gram stain of scrapings from the ulcer reveals numerous white blood cells and gram-negative rods. Topical antibiotics (fortified tobramycin and moxifloxacin) and cycloplegic eye drops are prescribed and the patient begins to use them immediately. The cultures eventually grow Pseudomonas species. The patient responds to the treatment and the corneal ulcer heals during the next 2 weeks. However, she is left with a central corneal scar and very poor vision that is not correctable with glasses. She currently is considering a corneal transplant to improve her vision.