Game 11
solve
in
1
Presenting with a white cloud-like appearance over the eye, is your patient Sarah.
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Her entire eye is red, and she white liquid pooling in her anterior chamber.
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On her eye you see various clouds, which was much worse than last week when she came in, since she only had a small cloud.
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The cloud is grey-white in colour.
Solve
in
2
She describes her symptoms.
These included things like:
- Gradual pain
- Sensation of foreign body
- Increasing tearing
- Increasing redness in the mirror
- Started a bit after she went to Malaysia.
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You do remember that she wore contact lenses to Malaysia since she did not have glasses.
You decide to stain the cornea just to get a better idea.
The fluorescin washes off and away with the tears
Solve
in
3
You note that the infiltrate is not well defined, with various feathery edges.
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Scraping won't do you any good, since the epithelium yields no results, so you decide to use confocal microscopy.
It is on the microscope that you notice white line structure inside the stroma and beginning to penetrate to the epithelium.
Last
Chance
You initially have differential diagnosis with bacterial keratitis, non-necrotising stromal keratitis and acanthamoeba keratitis. But:
1. No ulcers present, and the colour did not match bacterial. Lesions are also well defined
2. HSV generally has nothing to do with contact lenses, and there was no neovascularisation
3. Acanthamoeba may have Wesseley ring which was not present, and it also would present with a rough epithelium, which would be detected through stains
The
answer
Fungal Keratitis
- Feathery edges, multiple satellite lesions
- Can be detected through KOH or Sabouraud's Agar, but corneal scraping was out of the question
- More grey-white or grey-green than green-yellow
- Higher incidence in tropical regions, and patients usually have a history of trauma
- Depending if Sarah was naive or not, her immune system may not be as adapted to contact lenses