Photophobia hyperaemic lid margins and lid scaling

The question:

‘A 30-year-old man presents with photophobia, redness and pain in his left eye, which started three days ago. There is no discharge, but the eye is watery, especially in the sun. You observe hyperaemic lid margins and some lid scaling. There is an arcuate lesion on the cornea, just inside the limbus, which stains with fluorescein, accompanied by sectoral bulbar redness. He doesn’t wear spectacles or contact lenses. What is the likely diagnosis and how would you manage this?’

OT’s panel says...

Ceri Smith-Jaynes (CSJ): I’m going to say this is marginal keratitis caused by his blepharitis, but I’d keep ocular rosacea and Mooren’s ulcer in mind and ask about any autoimmune conditions. If there is separation between the stained lesion and the limbus, that would help firm up the diagnosis. I’d check the anterior chamber for signs and check visual acuity, although I’m not expecting it to be especially affected.

If it is marginal keratitis, at least it is inflammation caused by bacterial exotoxins rather than proper infection, and I can reassure the patient that it is self-limiting. I think we need to tackle the blepharitis with some lid cleaning, because that’s the likely cause of the problem: consider tea tree eyelid wipes or hypochlorous spray. If he’s in a lot of pain, he won’t want to be scrubbing his lids until it calms down a bit. 0.5% chloramphenicol drops four times a day and perhaps a steroid. I’d be interested to hear the others’ views on steroid drops for this…

Kevin Wallace (KW): I agree with Ceri that marginal keratitis is the most likely diagnosis – the key clue is the concurrent lid margin disease. If the patient doesn’t have ongoing lid problems it is important to carefully consider other causes of a monocular, painful red eye.

My treatment would depend on the severity. If the patient is very uncomfortable, I usually prescribe steroid drops with Chloramphenicol drops because that very quickly relieves the symptoms. Some recommend just using antibiotics and only adding steroids if that doesn’t improve things after a few days – but my own experience is that that hasn’t been as effective as steroids with antibiotic cover.

As usual patients should be informed of the side effects of steroids, but it’s a fairly short and not intensive course. Then, once the issue is resolved, I would recommend lid hygiene to reduce the chance of it happening again.

If it is marginal keratitis, at least it is inflammation caused by bacterial exotoxins rather than proper infection, and I can reassure the patient that it is self-limiting

Ankur Trivedi: I concur with Ceri and Kevin that the top of my list of differential diagnosis would be marginal keratitis. There is a wide spectrum of corneal inflammatory/infective presentations with a significant amount of overlap in the clinical picture, so I would want to cover off if there had been any previous similar episodes as I have seen some that have been recurrent. Also, I would ask about any recent ocular trauma to rule that out as a cause/vector.

In terms of management, I also concur with use of antibiotic with steroid – my slight difference would be to consider a combined medication (eg Maxitrol or Tobradex) that had both elements in a single, to simplify the application and aid compliance.

Maxitrol is variable as an ointment which allows for the medication to be in situ for a prolonged period versus drops, but smearing of vision can be a factor. Using the combined medication to get a head start on the lid margin disease is also useful. I have had patients rub a drop (or small application of ointment) using a clean dry fingertip along the lid margin, which can be useful if the patient is happy to do so.

CSJ: It’s interesting to hear my colleague’s views. The ophthalmologist I trained under for my independent prescriber hospital placement used to use Maxitrol ointment for this sort of presentation. He also found it useful in severe blepharitis cases.

KW: I tend to avoid Maxitrol, due to the higher risk of a reaction to it. I do use it occasionally for severe blepharitis when compliance is an issue, and I want to use a steroid and antibiotic, because it simplifies the regime.

CSJ: Kevin’s point is a good one. I’ve also seen a few people react to Maxitrol drops, as many patients used to have it for post-cataract surgery treatment in our area.

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