Download Cornea in Disguise: Atypical Presentation of Recurrent Corneal

Cornea in Disguise: Atypical Presentation of Recurrent Corneal Erosion
Katherine B. Lynch, OD
VA Connecticut, 950 Campbell Ave, West Haven, CT
Kimberly R. Rosati, OD
VA Connecticut, 950 Campbell Ave, West Haven, CT
Nancy Shenouda-Awad, OD, FAAO
VA Connecticut, 950 Campbell Ave, West Haven, CT
Charles Haskes, OD, MS, FAAO
VA Connecticut, 950 Campbell Ave, West Haven, CT
Abstract
Recurrent Corneal Erosion (RCE) can be complicated by unexpected manifestations similar to that of
an infectious or inflammatory etiology, making its initial diagnosis challenging. This poster highlights
an atypical case of RCE and its management.
I. Case History
 61 year old white male
 Chief complaint:
o Presented as an emergency
o Red eyes with irritation OD>OS for two weeks
o Associated clear discharge, foreign body sensation, light sensitivity,
sensitivity to the touch and stabbing pain when eyes are initially
opened, especially in the morning
o Decreased acuity both eyes
o Felt as if symptoms were worsening but denied precipitating event
 Ocular History
o Entropion surgery OS
o Resolved abrasion OS of unknown cause, treated on the outside
o Corneal Ulcer OS of unknown cause, treated on the outside
 Medical History
o Chronic Bronchitis
o Essential hypertension
o Hyperlipidemia
o Sleep apnea
o Schizoaffective disorder
o Morbid obesity
 Medications
o Albuterol
o
o
o
o
o
o
o
o
Aripiprazole
Budesonide
Hydrochlorothiazide
Lisinopril
Lorazepam
Simvastatin
Tiotropium 18MCG
Aspirin
II. Pertinent Findings
 Clinical
o Best corrected distance acuity:
1. 20/100 PH NI OD
2. 20/50-2 PH 20/40- OS
o Hypersensitivity of Cornea OD
o Slit Lamp Exam
1. 2+ Edematous lid without erythema OD
2. Meibomian Gland Dysfunction OU
3. 4+ injection OD, mild diffuse injection OS
4. Cornea
a. OD: White blood cell infiltration inferiorly in a dense band
with intact epithelium immediately above infiltration and
patches of white blood cell infiltration superiorly also with
an intact overlying epithelium, folds in descemet’s
membrane, central and inferior geographic sloughing of the
epithelium, and stromal edema. Map dystrophy apparent in
the intact epithelium.
b. OS: Map dystrophy with central whorl pattern of the
epithelium, and pigmented guttatae
5. Anterior Chamber OD: 1+ Cell and flare, OS: trace cell and flare
 Laboratory studies
o Viral swab cultures of the conjunctiva
1. Cytomegalovirus not detected
2. Herpes Simplex Virus not detected
3. Varicella-Zoster Virus not
4. No other viruses were detected
o Bacterial swab cultures of the conjunctiva
1. Gram stain
a. <1+ WBCs
b. <1+gram positive rods/organisms
2. 2+ Corynbacterium SP
a. No further workup of susceptibility was needed
 Imaging
o Anterior Segment photographs were taken to monitor for changes
III. Differential Diagnoses
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Primary:
o RCE due to Map Dystrophy and complicated by Floppy Eyelid Syndrome
Others:
o Epidemic Keratoconjunctivitis (EKC)
o Herpes Simplex Virus (HSV) with Neurotrophic Ulcer
o Fuch’s Endothelial Dystrophy
o Bacterial Keratitis due to infiltrate and anterior chamber reaction
IV. Diagnosis and discussion
 EKC was an unlikely diagnosis due to the significant epithelial loss OD, the
absence of a follicular reaction, and lack of immediate history of illness.
 HSV with Neurotrophic Ulcer was ruled out due to the appearance of an epithelial
defect not consistent with a neurotrophic cornea, corneal hypersensitivity, and
corneal infiltration.
 Fuch’s Endothelial Dystrophy was ruled out due to mild guttatae noted OS only
with focal versus diffuse edema.
 Bacterial Keratitis was ruled out due to the lack of epithelial defects overlying the
infiltrates, and lack of mucopurulent discharge.
o The positive bacterial cultures with Corynbacterium were of the
conjunctiva and were deemed to be due to meibomian gland dysfunction
not the cause of the corneal presentation.
 RCE with Map Dystrophy was the final diagnosis especially due to worsening
symptoms with mechanical lid opening in the morning.
o The history of corneal maps OU, the past unexplained corneal abrasion,
and the significant epithelial defect noted, all suggested RCE.
 Floppy eyelid syndrome was also a factor considered due to the asymmetry in
presentation between the eyes and the fact the patient sleeps mostly on his right
side, which may have worsened the exposure of the cornea OD.
o In addition, the patient has sleep apnea and is obese.
V. Treatment and Management
 Based on the above reasons, the patient was initially started on:
o Vigamox, every hour with loading dose for first 4 hours, both eyes
o Polysporin, twice per day both eyes
o Homatropine, night time only both eyes
o Non-preserved artificial tears, four times per day both eyes
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Treatment with topical antibiotics in this case was also used to treat and prevent any
bacterial infection that may be associated with the chronic lid disease and meibomian
gland dysfunction. He was later started on oral Doxycycline for more extensive
treatment.
The patient was presented to a cornea specialist and we followed him multiple times
weekly to monitor improvement.
Clinical findings showed improved acuity, improved symptoms and a healed epithelial
defect.
Once the corneal epithelium was intact, Pred Forte twice per day was added OU to reduce
the anterior chamber inflammation.
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Within two weeks, the epithelial defect and stromal edema had resolved and the vision
had significantly improved to:
o 20/25-2 OD, 20/30-2 OS
The patient continues to be followed for resolution of condition.
He is expected to be on chronic hypertonic treatment and lid disease management.
VI. Conclusion
 RCE is an easily overlooked diagnosis when associated with other unexpected
factors, such as a significant and/or bilateral epithelial loss, infiltration, and
anterior chamber reaction.
 With that said, atypical or more severe cases of RCE can be easily mistaken for a
more aggressive pathology.
 It is essential to carefully examine the cornea of both eyes and the intact
epithelium of the involved eye, especially in cases of asymmetric presentation, for
other factors such as dystrophies that may put the patient at higher risk of
developing corneal edema and RCE.
 With careful monitoring, topical antibiotics to prevent secondary infection and
aggressive lubrication to heal the epithelium, patients can expect a favorable
outcome and full recovery.
 Chronic treatment after resolution is critical.