Patient History

HPI: The patient is a 70-year-old retired contractor who presents with severe pain in the left eye, tearing, photophobia, and blurred vision after being kicked in the eye by his grandson 2 hours ago. He also reports a foreign body sensation in the left eye. He denies any flashing lights or floaters or mucous discharge from the eye.

Past Ocular History: Cataract surgery 3 years ago. No history of contact lens use, other eye trauma, amblyopia, or other ocular diseases.

Ocular Medications: None

Past Medical History: Hypertension - treated

Past Surgical History: Appendectomy

Past Ocular Family History: No history of macular degeneration, glaucoma, or other blinding diseases.

Social History: Denies alcohol, tobacco, or illicit drug use.

Medications: Hydrochlorothiazide

Allergies: None

ROS: Denies recent illnesses, CNS, heart, lung, GI, skin, or joint problems.

Ocular Examination

Visual Acuity (cc): OD: 20/20 OS: 20/50 PH NI

Intraocular Pressure (tonometry): OD: 13 mmHg OS: 15 mmHg

Pupils: OU equal, round, and reactive, no APD

Extraocular Movements: OU full. No nystagmus.

Confrontation Visual Fields: Full to finger counting OU

External: Mild periorbital erythema more prominent on the left lower eyelid and cheek.

Slit Lamp:

Eyelids and Lashes: Mild swelling of the left lower eyelid. Everted fornices and no foreign body noted OU. Conjunctiva/Sclera: OD normal; 1+ conjunctival injection OS, no conjunctival fluorescein staining OS. Cornea: OD clear; 2 mm by 2 mm corneal epithelial defect (+ fluorescein staining), no infiltrate or corneal stromal thinning. Anterior Chamber: OU deep and quiet, no cells

Iris: OU normal

Lens: OU normal

Anterior Vitreous: Clear OU

Dilated Fundus Exam: OD: Clear vision, CDR 0.2 with sharp margins of the optic disc, flat macula with normal foveal light reflex, normal vessels, and peripheral retina. OS: Clear vision, CDR 0.2 with sharp margins of the optic disc, flat macula with normal foveal light reflex, normal vessels, and peripheral retina. Other: None

Diagnosis and Discussion Diagnosis:

Traumatic corneal abrasion

Discussion:

Differential Diagnosis:

The patient presents with a superficial traumatic corneal abrasion based on clinical signs and symptoms. The differential diagnosis would include infectious keratitis (including herpetic keratitis), recurrent corneal erosion, neurotrophic epithelial defect, or contact lens-associated keratopathy.

Definition:

A corneal abrasion is a disruption of the corneal epithelium. This is most commonly caused by trauma, contact lens wear, or foreign body. Typical symptoms include intense irritation, foreign body sensation, eye pain, excessive tearing, and/or inability to open the eyes due to pain and light sensitivity. Most abrasions result in significant discomfort for the patient due to the high innervation of the cornea.