Melissa Valdellon

Patient case for June 23, 2023

I am very grateful to work in a community clinic where I can speak with fellow doctors of different specialties about our mutual patients and they feel welcome to walk over anytime they want to discuss one of their patients with any eye concerns. This following case is just one recent example.

One of the clinic pediatricians came by asking if I could see one of her patients. The patient is a 13 year old female complaining of a sudden onset red right eye that she noticed when she first noticed upon waking up four days ago. Besides the redness, she says it felt like something was in her eye and irritating it. She reports that the eye has been watery with some discharge. She doesn’t remember anything getting into her eye, but she says she used some shimmery makeup two days prior and thinks maybe that could have irritated it.

After a day of no improvement, she went to the emergency room and was prescribed polytrim antibiotic eye drop. She reports good compliance with using the medication every 3 hours as prescribed but there has been no change in the redness or irritation and now the redness is starting to affect the left eye, though not as bad yet.

Overall, she says her eyes feel itchy and they burn. They don’t hurt really but she does have a small headache. And on further questioning, she reports that she hasn’t been recently sick and no one in her family and no one she’s been around in the last few days has been ill either.

Medically, the patient is very health with no conditions, no allergies, and is not taking any other medications besides polytrim eye drop.

Incoming visual acuity is 20/20-3 and 20/25+2 with easy pinhole to 20/20 each eye. Pupils and EOMs are normal both eyes.

Anterior segment exam findings shows clear lids and lashes, but conjunctival hyperemia, chemosis, mixed papillae and follicles OD worse than OS. There is patchy 1+ PEE peripherally on the cornea OD but otherwise clear centrally and no PEE in the left eye. Anterior chambers are deep and quiet, irides are brown and flat, lenses are clear, and vitreous is normal in both eyes. A small pupil posterior segment evaluation shows pink, distinct nerves with 0.40 cupping both eyes, shiny RNFL, normal vasculature, and flat and even macula of both eyes. IOPs are equal at 12/12 with Goldmann tonometry.

Given what you know, does this match the ER diagnosis of bacterial conjunctivitis? What in the exam findings suggest that this is bacterial in nature and what doesn’t?

What else is on your differential diagnosis list? How can you rule in or out allergic conjunctivitis? Viral? Iritis or uveitis? Do you think the patient’s headache is related to her ocular symptoms or not? What about her eye makeup use two days prior?

I can’t wait to read your thoughts!

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