Diagnosis «

CASE STUDY 2 | Paul Karpecki, OD, FAAO

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Diagnosis

Image: Western Ophthalmics

The patient demonstrated significant reduction of corneal sensitivity in both eyes, with sensitivity in the left eye reduced to near zero.

Based on the patient’s history and examination findings, what do you think my principal diagnosis was?

○	a. Chronic epithelial defect associated with her severe dry eye disease There is no doubt that this patient had severe dry eye—she had a history of dry eye, prominent MGD, scant tear meniscus height, and tear hyperosmolarity, but I did not consider dry eye to be the primary cause of her corneal lesion. Please select again.
○	b. Herpetic epithelial keratitis This was not my diagnosis. Characterized by a central location and Descemet’s membrane folds and stromal swelling, this patient’s corneal lesion lacked the distinctive features of an active herpetic viral infection, such as dendritic or geographic ulceration and significant stromal inflammation. Additionally, herpetic epithelial disease rarely persists the way this patient’s had. It is typically self-limited and will resolve without intervention. Please select again.
○	c. Neurotrophic keratitis Yes. Poor epithelial healing and loss of corneal sensitivity are characteristic features of neurotrophic keratopathy.¹ In this patient, the diagnosis of neurotrophic keratopathy is further supported by history of viral infection (potentially herpes simplex keratopathy associated with corneal sensory impairment) and the appearance of the epithelial defect.¹ According to the classification system of neurotrophic keratitis based on severity, her condition was more advanced in the left eye (stage II, characterized by persistent epithelial defect) than the right (stage I, characterized by superficial punctate keratitis).¹ This implies that previous herpetic keratopathy likely played a more important role in the development of the epithelial defect, though diabetes might have predisposed both eyes to neurotrophic keratopathy. Sacchetti M, Lambiase A. Diagnosis and management of neurotrophic keratitis. Clin Ophthalmol. 2014;8:571-9.
○	d. Toxic ulcerative keratoconjunctivitis There is no evidence to suggest that the patient’s corneal lesion had resulted from toxicity of topical medications. Please select again.

Paul Karpecki, OD, FAAO, works in Corneal Services and is clinical research director at the Kofﬂer Vision Group in Lexington, KY. He is a consultant for Bausch + Lomb and Bio-Tissue Inc.

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