Cornea and Conjunctiva

A 24-year-old contact lens wearer presents with severe, excruciating right eye pain, photophobia, and a foreign body sensation after a scratch from a fingernail. Slit-lamp evaluation with fluorescein staining reveals a superficial uptake of stain on the outer epithelium. What is the diagnosis, and what is the mandatory first-line drug class?

Corneal abrasion; Topical fluoroquinolones (e.g., Ofloxacin)

Name three specific clinical interventions or medication classes that are strictly contraindicated when managing a corneal abrasion or corneal ulcer.

• Eye patching

• Topical steroids

• Prescribing topical anesthetics

Multiple linear abrasions visualized via fluorescein stain on the upper portion of the cornea are known as the ________, which points to a foreign body trapped beneath the upper lid.

"Ice-Rink Sign"

A patient who routinely sleeps in their soft contact lenses presents with extreme ocular pain, photophobia, and purulent discharge. Physical exam reveals a distinct, visible round white spot on the clear part of the eye. What is the diagnosis, and what does it represent?

Corneal ulcer; a deeper epithelial defect involving the underlying stroma

What is the 1st-line antibiotic regimen for a mild corneal ulcer?

Topical Ciprofloxacin is given every 30–60 minutes

What is the gold standard antibiotic regimen for a severe, vision-threatening ulcer?

Cephalosporin or Vancomycin + an Aminoglycoside

While superficial corneal ulcers can heal within 2–3 days, deep or highly infectious ulcers may take 1–2+ weeks and severe cases may ultimately require a ________ due to scarring risk.

Corneal transplant

 An adult patient presents with acute-onset unilateral eye pain, a purulent discharge, blurred vision, and a "hazy" cornea. Slit-lamp inspection reveals an accumulation of white blood cells pooling in the bottom of the anterior chamber, but the palpebral conjunctiva is spared. Diagnosis?

Bacterial keratitis with a hypopyon

What diagnostics are used to isolate the underlying pathogen in suspected infectious keratitis before or during treatment failure?

• Corneal scraping for Gram stain

• Cultures

• KOH wet mount

• Agar plates

A classic pathognomonic physical finding on fluorescein staining that confirms epithelial invasion of Herpes Simplex Virus (HSV) keratitis is a ________.

Dendritic corneal ulceration (or dendritic ulcer)

A patient presents with a severe headache, fatigue, a stabbing pain in their forehead, and a vesicular rash clustered tightly at the tip of their nose. What is this nasal sign called, and what specific vision-threatening condition does it alert you to?

Hutchinson sign; Herpes Zoster Ophthalmicus (Viral Keratitis)

What is the 1st-line medical treatment for epithelial Herpes Simplex Virus (HSV) keratitis?

Topical antivirals (Acyclovir 3% ointment)

What is the 1st-line medical treatment for stromal Herpes Zoster Virus (HZV) keratitis?

Oral/IV antivirals +/- topical steroids

On a physical exam, a deep, purplish-red ring of redness radiating tightly outward from the edge of the cornea is called a ________ and is an hallmark indicator of keratitis over conjunctivitis.

Ciliary flush (or limbic flush)

 A 42-year-old construction worker who spends most of his days outdoors without sunglasses notes a small, painless, yellowish raised nodule on the white part of his eye adjacent to the palpebral fissure. It does not encroach upon the cornea. What is the diagnosis and first-line management?

Pinguecula; supportive care (reassurance/leave it alone)

What are the primary environmental etiological factors responsible for driving the progression of both pingueculas and pterygiums?

Repeated exposure to wind, sun, sand, dust, or chronic irritation

A fleshy, vascular triangular mass of bulbar conjunctiva that actively encroaches onto the clear cornea is a ________, which can cause permanent ________ in children if it blocks the visual axis and goes untreated.

Pterygium; amblyopia

An avid surfer presents with a triangular wedge of vascular tissue tracking from the nasal commissure onto the medial edge of his left cornea. He complains of a persistent foreign body sensation. What is the diagnosis, first-line treatment, and definitive gold-standard treatment if vision becomes impaired?

Pterygium ("Surfer's eye"); first-line: Artificial tears; gold-standard: Surgical resection

A 10-year-old boy presents with a sore throat, mild fever, and a red right eye featuring a profuse, watery discharge. On exam, noticeable follicular bumps are found in the inferior fornix, and he has a tender ipsilateral preauricular lymph node. What is the most likely pathogen?

Adenovirus (Viral conjunctivitis)

What is the first-line supportive care recommendation for standard viral conjunctivitis?

Artificial tears and cold compresses

What is a clinical pearl regarding transmission for standard viral conjunctivitis?

Highly contagious, stay home the first couple of days

 In stained scrapings and exudates, a viral conjunctivitis sample will predominantly show ________, whereas a non-STI bacterial conjunctivitis sample will reveal ________.

Monocytes; bacteria and PMNs (polymorphonuclear cells)

A pediatric patient presents with severe eyelid swelling, bilateral conjunctival erythema, and a thick, gooey, mucopurulent discharge that mats the eyelashes shut in the morning. What is the diagnosis, and what are the top three most common bacterial etiologies?

• Bacterial conjunctivitis

  • Haemophilus

  • Streptococcus

  • Moraxella

What is the first-line topical antibiotic options for non-STI bacterial conjunctivitis?

Erythromycin ointment or Trimethoprim-polymyxin B drops;

What is the first-line topical antibiotic options for non-STI bacterial conjunctivitis for contact lenses?

Fluoroquinolones (e.g., Ofloxacin, Moxifloxacin)

Hyperacute conjunctivitis presenting with a rapid progression of severe eyelid edema, marked chemosis, and a copious, profuse purulent exudate suggests a gonococcal infection, which presents on a Gram stain as ________.

Gram-negative diplococci

A sexually active adult presents with a persistent red eye, mucopurulent discharge, a gritty foreign body sensation, and an enlarged preauricular lymph node. The condition has failed to improve despite 2 weeks of OTC and generic antibiotic eye drops. What is the suspected diagnosis and first-line treatment?

Chlamydial conjunctivitis (Adult Inclusion Conjunctivitis)

• Systemic Azithromycin 1g PO once

What are the clinical management steps and treatment regimens for a neonate presenting with symptomatic gonococcal conjunctivitis?

Ceftriaxone (Rocephin) IM and saline eye irrigation; must run a full STI panel

A patient with a known history of asthma and eczema presents with intense, severe bilateral eye itching, generalized conjunctival redness, tearing, and stringy mucoid discharge. Everted lids reveal a "cobblestone" appearance of the palpebral mucosa. What is the diagnosis?

Allergic conjunctivitis

Outline the stepped management strategy for allergic conjunctivitis, starting from conservative measures up to the therapies used for severe flares.

1. Avoid allergens, cold compresses, OTC artificial tears.

2. Antihistamine + mast cell stabilizer combo drops.

3. Short-term low-potency topical steroids/NSAIDs.

Ocular decongestants like tetrahydrozoline (Visine) should be used very sparingly because prolonged use causes a worsening of symptoms known as ________.

Rebound hyperemia

A patient arrives in the emergency department after an accidental household chemical splash to the face. What are the immediate diagnostic and management steps that must be taken?

Copious irrigation (water/saline), then assess pH and visual acuity; immediate ophthalmology referral

A patient on Warfarin therapy presents in a panic after waking up to find a large, dark-red pool of blood masking the white of her right eye. She denies pain, trauma, discharge, or any changes to her baseline vision. What is the diagnosis and management?

Subsubconjunctival hemorrhage; supportive care (reassurance)

To diagnose Keratoconjunctivitis sicca (Dry eyes) by objectively measuring the actual rate of a patient's tear production, clinicians utilize the ________ test.

Schirmer test