This 60year old woman is status post LASIK, OU, 7 months. Everything went well until this.
She presents with mild light sensitivity, but not photophobic. The fellow eye is as red with and looks like this.CF 7ft is the vision PHNI. Pupils are reactive. No cells/flare in the AC. Cornea folds (~15% to 20% CCT increase) and obivous demarcation of the flap border where none was evident. Afebrile, normal pulse, normal oxygenation,. Cutlure negative(!) (97F)
What would you do?
new URL http://bit.ly/ydMNXH
This patient needs full investigations. By culture do you mean corneal scrapes?
Any medical history i.e Rheumatoid arthritis?
Needs flap lift and scrape at the base of the stroma and possibly washout with antibiotics but at least this would lead to a higher yield of microorganisms.
Then, the photo is not great but I can see some corneal thinning so inflammatory markers need to be checked.
Regards
Michael
Michael,
Because this is a Grand Rounds case, what are some possible causes? I know I’m a bit mean but 1880 followers would love to konw.
Richard
I haven’t looked at the patient, but I might prescribe an antibiotic for coverage, Pred Forte 1% QID and Muro 128 TID. Get their corneal surgeon involved if accessible, if not, follow up with your cornea guy. This might be a kind of inflammatory Ectasia. She needs to see her surgeon stat. It unfortunately looks like the flap interface could split back open with enough edema, that’s a rough case. How high was her Rx pre-Tx? Was she a high myope? This might be post-operative ectasia or endothelial thinning.
Thanks for your reply.
IN this case, the patient had an unremarkable post operative course. If this culture negative, as stated, what do you think are possible causes? Actually, I would bump the PF1% to QHR for the first 3 days.
I think she got shaved a bit thin and she’s got some ectasia causing a split at the interface.
What about neurotrophic? also is there a history of HSV?
Brad,
Thanks. No h/o neutrophic keratitis. No h/o HSV.
if it isn’t infectious, if it isn’t post surgical complication…then it could be…”
Bullous Keratopathy?
Possibly, but bilateral and in the inferior part of the cornea?
HCV related Sjogren’s Syndrome?
Frank,
Getting closer. What about a hepatitis patient in the acute phase?
I was just going to ask for clues from review of systems…
personal physician-Interferon, hctz , b12, ER- keflex
why the interferon?
Hepatitis
oh I get your comment to Frank now, hepatitis related keratitis.
It is not the hepatitis that is causing corneal opacification. But it is related.
That is very interesting. Thank you very much for sharing.
On monday, I will share what the final diagnosis was.
omg cliffhanger.
^^ that was supposed to be me.
from rosalyn? I was wondering.
Hi Richard,
Which interferon therapy? Was it Pegasys (Peg interferon A 2 alpha)? There have been documented problems with Pegasys with Ribavirin.
Thanks,
Deegan
Deegan,
It was p-interferon.
By the way, I’m slowly retiring this blog address. All of these posts are now on http://tips4EyeDocs.com. Could you post this reply also there? That post is http://bit.ly/ydMNXH.