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CASE PRESENTATION. Identifying Data. RM 79/F Cubao , Quezon City. Chief Complaint. Blurring of vision.

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identifying data
Identifying Data
  • RM
  • 79/F
  • Cubao, Quezon City
chief complaint
Chief Complaint
  • Blurring of vision
slide4

Patient is a known case of senile mature cataract OS and microbial keratitis with corneal ulceration OD which is managed by moxifloxacin and atropine. The patient is supposedly for scheduling of cicatricialectropion repair

history of present illness
History of Present Illness
  • 3d PTC
  • Blurring of vision
    • Right eye
    • Progressive, gradual
    • Increasing dependency on shapes
    • Declining ability to distinguish faces
    • No pain, redness, pruritus, trauma,
    • No fields of dark areas, flashes
  • No complaints on the left eye

Consult

past medical history
Past Medical History
  • Uncontrolled hypertension, Stage II
  • Diabetes Mellitus, Type 2
    • Last checkup was >3 years ago
  • Fire victim (39y ago)
    • Multiple burn scars on the head, body and extremities
  • s/p ECCE w/ extraocular lens implant, OD, 2010
    • QMMC
  • s/p Dacryocystorhinostomy, OD, 2010
    • St. Lukes
  • Cicatricialectropion, OD
personal social history
Personal Social History
  • Lives with relatives
  • Unemployed
  • No alcohol intake
  • No use of illicit drugs
  • (+) Smoking
    • Ocassionally
    • 5 sticks/day at most
family history
Family History
  • (+) Hypertension
  • (+) Diabetes
  • (-) Asthma
  • (-) Tuberculosis
review of systems
Review of Systems
  • General: (-) fever, weight changes, weakness,
  • Skin/Breast: Rash, pruritus, changes in hair growth or loss, nail changes
  • HEENT: (-) headache, dizziness, light-headedness, tearing, neck stiffness, double vision, dark patches in vision
slide10

Cardiovascular: (-) Precordial pain, palpitations, syncope, edema, cyanosis, hypertension, heart murmurs

  • Respiratory: (-) shortness of breath, wheezing, stridor, cough, hemoptysis, respiratory infections,
  • Gastrointestinal: (-) Poor Appetite, dysphagia, abdominal pain, nausea, vomiting, constipation, or diarrhea, recent changes in bowel habits
  • Genitourinary: (-) frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color of urine
  • Musculoskeletal: (-) Pain, swelling, redness or heat of muscles or joints, muscular weakness, atrophy, cramps
  • Neurologic/Psychiatric: (-) anxiety, depression, previous psychiatric care, unusual perceptions, hallucinations
physical exam
Physical Exam
  • General: Awake, comfortable, cooperative
  • Vital Signs
    • BP 130/80 HR 80 RR 20 T 37
  • Not in pain or cardiorespiratory distress
slide12

Skin: (+) Age spots, multiple burn scars on face and extremities with contractures

  • Head: No open wounds, (-) erythema, (-) aural or nasal discharges, dry lips, (-) lymphadenopathies
slide13

Chest

    • Symmetric chest expansion, (-) retractions, (-) rales, crackles, clear breath sounds
    • Adynamic precordium, (-) murmurs, distinct S1 and S2
  • Abdomen
    • Flat, soft, (-) organomegalies, normoactive bowel sounds
  • Genitourinary exam
    • Deferrred
  • Extremities
    • Thin, (-) limitations range of movement, 5/5 muscle strength
ophthalmologic exam
Ophthalmologic Exam
  • Visual Acuity
slide20

Admitting diagnosis:

    • Corneal ulcer, OD
  • Plan
    • Admission
      • For treatment of hypopyon
workups done
Workups done
  • Chest X-Ray
    • Fibrosis, left upper lung
    • Atheromatous aorta
  • Electrolytes
    • Na 136 (136-145)
    • K 4.9 (3.5-5.1)
    • Cl 103 (97-102)
slide22

CBC

    • Hgb105
    • Hct0.31
    • WBC 4.2
    • Plt adequate
  • Urinalysis
    • Yellow
    • Sl. Turbid
    • 1.010
    • 6
    • (-) sugar
    • (-) albumin
    • WBC 20-25
    • RBC 2-5
slide23

Corneal Scrapings (January 16)

    • No growth after 4 days
problem list
Problem List
  • Blurring of vision
  • Corneal Ulcer
    • Microbial keratitis
  • Cicatricialectropion
  • Hypertension
  • Diabetes
microbial keratitis corneal ulcer
Microbial keratitis/Corneal Ulcer
  • Keratitis  Inflammation of the cornea.
  • Central ulcers usually are infectious ulcers secondary to corneal epithelial damage.
common symptoms
Common symptoms
  • Since the cornea has many pain fibers, can cause pain and photophobia.
  • Occasional blurring of vision, especially if centrally located.
  • Although tearing and photophobia commonly accompany corneal disease, there is usually no discharge except in purulent bacterial ulcers.
slide28

The lesion is situated centrally, away from the vascularized limbus.

  • It is often accompanied by hypopyon, a collection of inflammatory cells seen as a pale layer in the inferior anterior chamber.
pertinent history
Pertinent History
  • Contact lens wear
  • Trauma
  • Topical ocular medications
  • Decreased immunologic defenses
  • Aqueous tear deficiencies
  • Recent corneal disease
  • Structural alteration or malposition of the eyelids
workup
Workup
  • Examination of corneal scrapings, stained with Gram's and Giemsa's stains
  • Cultures for bacteria are usually obtained in all cases at first presentation.
  • It is important that therapy is not withheld if an organism cannot be identified on microscopic examination of corneal scrapings, although it may have to be empirical based upon the clinical features.
slide31

Central suppurative ulceration was once caused almost exclusively by S.pneumoniae infection complicating corneal trauma, particularly occurring in patients with obstructed nasolacrimal ducts.

dacryocystorhinostomy
Dacryocystorhinostomy
  • DCR is a surgical procedure to restore the flow of tears into the nose from the lacrimal sac when the nasolacrimal duct is blocked.
    • 77.5% Ex.DCR
    • 90% in Ex.DCR with silicone intubation
ectropion
Ectropion
  • Usually bilateral and is a frequent finding in older persons.
  • May be caused by relaxation of the orbicularis oculi muscle, either as part of the aging process or following seventh nerve palsy.
  • The symptoms are tearing and irritation.
  • Exposure keratitis may occur.
cicatricial ectropion
Cicatricialectropion
  • Caused by contracture of the anterior lamella of the lid.
  • Treatment requires surgical revision of the scar and often skin grafting.
slide36

Hypertension

    • Currently managed on clonidine, amlodipine
  • Diabetes
    • No medications given
course in the wards
Course in the Wards
  • Day 2
    • Patient noted blurring of vision on the left eye, abrupt, no trauma, pain, pruritus, tearing,photophobia
slide38

Day 3

    • GS/CS of corneal scrapings
    • Start tobramycin
slide40

Day 5

  • Ulcer, OD
    • Dimensions: 2.2mm x 2mm
slide41

Day 6

    • Plan: for cicatricialectropion repair once corneal ulcer resolves
    • Do lid taping before sleeping
slide42

Day 7

    • Decreased level of hypopyon
slide43

Day 9

    • Ulcer, OD
      • Dimensions: 1.6mm x 1.6mm
    • Decreased level of hypopyon
slide44

Day 10

    • Ulcer, OD
      • Dimensions: >1mm X >1mm
    • (+) hypopyon