Anterior Segment and the eyelids:
This 50 year-old female contact lens wearer presented with a one-day history of severe right eye pain. She attended the eye casualty two day earlier with a contact lens-related corneal abrasion and was prescribed topical chloramphenicol qds.
a. What is the most likely pathogen causing this appearance?Pseudomonas especially pseudomonas aeruginoa.
This is the most common pathogen in contact lens-related microbial keratitis. It is commonly seen in the biofilms of the contact lenses and also in contact lens cases.
It often presents with a rapidly progressive corneal ulcer with large epithelial defects, dense anterior stromal infiltration and mucoid material clinging to the lesion
b. Was the patient given the right antibiotic cover in her first visit?No.
Pseudomonas aeruginosa is resistant to chloramphenicol but sensitive to gentamicin and fluoroquinolone such as ofloxacin or ciprofloxacin. In any patient with contact lens-related abrasion, antibiotic prophylaxis should either be gentamicin or a fluoroquinolone.
c. How would you manage this patient?
- The ulcer should be scrapped for Gram stain; culture and sensitivity. If the contact lens had not been disposed this should also be sent for culture and sensitivity.
- The patient should be admitted for intensive antibiotic which can be a monotherapy with fluoroquinolone or the conventional dual therapy with fortified gentamicin (1.5%) and cefuroxime (5%) drops.
- Cycloplegic such as atropine should be given to reduce the pain and at the same time prevent posterior synechiae which can lead to iris bombe'.
- Analgesia is prescribed for pain.
- The response of the ulcer to therapy should be carefully monitored as the ulcer may progress to corneal perforation necessitating tissue adhesive or surgical maneuvers such as tectonic graft.
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