Managing challenging corneal cases

Consultant ophthalmic surgeon, Bita Manzouri, outlined a series of challenging corneal cases she has encountered in practice during her presentation, Demystifying mysterious corneal cases, at 100% Optical (London ExCel, 23-25 April).

During her talk, Manzouri acknowledged the important role optometrists played during the COVID-19 pandemic.

“Within the hospital service we are immensely grateful to optometrists,” she said.

“It has gone to show how a lot of patients don’t need to be seen in the hospital environment,” Manzouri added.

Case 1

The first case she detailed was a 58-year-old patient who had experienced redness and blurred vision in her right eye over the previous day.

The patient had last worn contact lenses three days before attending the appointment. She had received treatment for a brain tumour two decades ago.

Manzouri noted that the patient was given antibiotics after an initial diagnosis of contact lens-associated keratitis. However, two days later her vision had deteriorated and a corneal infiltrate was visible in her right eye.

The diagnosis was refined to a sterile infiltrate with steroids added to the patient’s course of treatment.

Treatment with steroids was reduced after the patient was diagnosed with neurotrophic keratitis.

By day 17, the patient was experiencing poor right eyelid function. She had a non-healing epithelial defect by day 24.

Manzouri noted that treatment with a bandage contact lens was not suitable for a patient with a neurotrophic cornea. A lateral tarsorrhaphy was performed where a section of the upper and lower eyelids are sutured together.

By day 41, the epithelial defect had halved in size with a central tarsorrhaphy performed on day 43.

The tarsorrhaphy was opened on day 61 revealing that the epithelial defect had resolved.

Manzouri shared that a small gold weight was inserted in the upper eyelid to improve the patient’s blink reflex.

By day 134, there was no epithelial defect and the patient was capable of weak blinking in the affected eye.

“These challenging cases can take time to resolve,” Manzouri emphasised.

Reflecting on the lessons learned through the case, Manzouri highlighted the importance of taking a full ocular and medical history.

She added that corneal sensation was only tested 10 days after the patient presented for treatment, despite the signs in this case being out of proportion to the patient’s symptoms.

“I test corneal sensation in virtually every patient who comes in,” Manzouri said.

She noted that a hallmark of non-infectious degenerative corneal disease is decreased or absent corneal sensation.

Causes include neurotrophic keratitis, herpes simplex virus and intracranial space-occupying lesions.

Case 2

The second case Manzouri detailed was a 68-year-old man with reduced and blurred vision in his left eye who presented for treatment in May 2020.

After being diagnosed with herpes simplex keratitis, he was treated with topical antibiotics and topical steroids as well as an oral antiviral medication.

The patient began experiencing a loss of hearing in his left ear as well as left facial numbness.

He was then diagnosed with exposure keratopathy, and was treated with lubricating eye drops as well as eye taping.

The patient was found to have a lesion in his left sinus. The tumour was inoperable and had a poor prognosis.

A perforated epithelial defect was managed with a bandage contact lens.

Manzouri noted that exposure keratopathy results from decreased lubrication of the ocular surface due to inadequate eyelid closure.

This condition can be linked to problems with the fifth or seventh cranial nerve.

She outlined how many patients who were ventilated in the intensive care unit during the COVID-19 pandemic experienced ocular surface issues, with gases blown from their neck to the eyes.

Cases 3 and 4

The final two cases Manzouri shared involved patients with corneal issues linked to systemic disease.

An 83-year-old patient presented with a three-day history of redness and reduced vision.

The patient was initially diagnosed with marginal keratitis. A month later the patient experienced corneal melting and was diagnosed with peripheral ulcerative keratitis.

The patient was given oral steroids and oral immunosuppressants following abnormal blood results.

Manzouri then recounted the case of a 60-year-old female with Sjögren's syndrome secondary to rheumatoid arthritis.

The patient initially presented with a painful red eye and was given intensive topical antibiotics with clinicians suspecting infective keratitis.

After no growth was found on corneal scrapes, the diagnosis was refined to marginal keratitis within steroids added to the treatment regime.

It was subsequently discovered that the patient had previously received antibody injections to control her rheumatoid arthritis.

However, these injections were paused after the patient experienced a urinary tract infection.

“It was quite clear to me that her rheumatoid arthritis was not controlled,” Manzouri said.

The final diagnosis was peripheral ulcerative keratitis secondary to uncontrolled systemic disease.

Key takeaways

In closing her session, Manzouri shared guidance for optometrists working in the community.

Corneal symptoms that should prompt a clinician to consider referral can be remembered by the acronym, RSVP – redness, sensitivity to light, changes in vision and pain.

She advised against starting steroid treatment within a community setting. Recommended treatment options included preservative-free lubricants, topical antivirals, topical mucolytic agents and, for infiltrates, topical antibiotics.

She encouraged optometrists to advise contact lens wearers to bring their contact lenses, contact lens solution and case to their hospital appointment.

Optometrists should feel free to ask for advice from secondary care if they are unsure how to manage a patient, with Manzouri highlighting the value of providing images when seeking guidance.