Photo Quiz

Painful Red Eye



FREE PREVIEW Login or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.

Am Fam Physician. 2013 Jan 15;87(2):127-128.

A 46-year-old man presented to the emergency department with unilateral pain in his left eye that began one day earlier. He had redness and a foreign body sensation. There were no vision changes, discharge, trauma, or recent upper respiratory tract symptoms.

On examination, his pupils were reactive to light with normal ocular motor function. He had consensual photophobia. Slit lamp examination showed ciliary flush and cell flaring, but no conjunctival injection. The patient was further evaluated with fluorescein staining (Figure 1).

Figure 1.

View Large


Figure 1.


Figure 1.

Question

Based on the patient's history, physical examination, and microscopy findings, which one of the following is the most likely diagnosis?

A. Foreign body.

B. Fungal keratitis.

C. Herpes keratitis.

D. Sarcoidosis.

Discussion

The answer is C: herpes keratitis. Herpes simplex virus is one of the leading causes of infectious keratitis resulting in blindness. Herpes keratitis is the most common ocular form of herpes infection and usually presents as an infection of the superficial epithelium with dendritic lesions in this layer.1 Symptoms of herpes keratitis vary but may include pain, blurred vision, sensitivity to light, red eye, watery discharge, or foreign body sensation. Recurrent episodes are common.

The diagnosis is made based on history and slit lamp examination.1 This patient's examination with f luorescein staining revealed a dendritic lesion (Figure 2). Laboratory testing is generally not indicated. Herpes keratitis is treated with antiviral therapy.2

Figure 2.

Slit lamp examination with fluorescein staining shows a dendritic lesion (arrow) in a patient with herpes keratitis.

View Large


Figure 2.

Slit lamp examination with fluorescein staining shows a dendritic lesion (arrow) in a patient with herpes keratitis.


Figure 2.

Slit lamp examination with fluorescein staining shows a dendritic lesion (arrow) in a patient with herpes keratitis.

Patients with a foreign body may have excruciating pain, tearing, and a scratchy sensation with blinking. Slit lamp examination may reveal a foreign body in the anterior or posterior chamber. However, if the object is not present, fluorescein staining may demonstrate a corneal epithelial injury or defect.1

Patients with fungal keratitis may have a history of trauma with vegetative matter, or long-term steroid use.1,3 Common symptoms include pain, red eye, foreign body sensation, and discharge. Typical slit light examination findings include a dry, gray, elevated infiltrate and satellite lesions. Diagnosis requires laboratory confirmation using a fungal culture.

Ocular sarcoidosis can manifest before the presentation of systemic sarcoidosis. Uveitis is a common ocular manifestation of sarcoidosis.4 Examination shows redness in the corneal area. Patients present with bilateral ocular pain, photophobia, and decreased vision, and granuloma formation can be seen in the conjunctiva and uvea.

Summary Table

Condition Examination findings Characteristics

Foreign body

Foreign body in anterior or posterior chamber; corneal epithelial injury/defect

Excruciating pain, tearing, scratchy sensation with blinking

Fungal keratitis

Dry, gray, elevated infiltrate, and satellite lesions

History of trauma with vegetative matter, or long- term steroid use; pain, red eye, foreign body sensation, or discharge

Herpes keratitis

Dendritic lesions in the epithelial layer

Pain, blurred vision, sensitivity to light, red eye, foreign body sensation, or watery discharge

Uveitis from sarcoidosis

Redness in corneal area, decreased visual acuity

Bilateral ocular pain and photophobia; granuloma formation in the conjunctiva and uvea

Summary Table

View Table

Summary Table

Condition Examination findings Characteristics

Foreign body

Foreign body in anterior or posterior chamber; corneal epithelial injury/defect

Excruciating pain, tearing, scratchy sensation with blinking

Fungal keratitis

Dry, gray, elevated infiltrate, and satellite lesions

History of trauma with vegetative matter, or long- term steroid use; pain, red eye, foreign body sensation, or discharge

Herpes keratitis

Dendritic lesions in the epithelial layer

Pain, blurred vision, sensitivity to light, red eye, foreign body sensation, or watery discharge

Uveitis from sarcoidosis

Redness in corneal area, decreased visual acuity

Bilateral ocular pain and photophobia; granuloma formation in the conjunctiva and uvea

Address correspondence to Mohenish Singh, LT, MC, USN, at Mohenish.Singh@med.navy.mil. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disclose.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Navy Medical Department or the U.S. Navy at large.

REFERENCES

1. Kunimoto DY, Kanitkar KD, Makar M; Wills Eye Hospital. The Wills Eye Manual. Office and Emergency Room Diagnosis and Treatment of Eye Disease. 5th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2008.

2. Guess S, Stone DU, Chodosh J. Evidence-based treatment of herpes simplex virus keratitis: a systematic review. Ocul Surf. 2007;5(3):240–250.

3. Thomas PA. Fungal infections of the cornea. Eye (London). 2003;17(8):852–862.

4. Heiligenhaus A, Wefelmeyer D, Wefelmeyer E, Rösel M, Schrenk M. The eye as a common site for the early clinical manifestation of sarcoidosis. Ophthalmic Res. 2011;46(1):9–12.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

A collection of Photo Quizzes published in AFP is available at http://www.aafp.org/afp/photoquiz.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.


Copyright © 2013 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Download PDF
  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

More in Pubmed

Navigate this Article