A 32-year-old black male presented for a follow-up eye examination after an emergency room visit.
His chief complaint was a red, swollen left eye, without pain, which he had for the past two days.
He said he had splashed an automotive cleaning solution in the eye. He explained the ER had given him a course of I.V. antibiotics when he presented there about 30 hours before.
His systemic history was noncontributory.
The patient"s right eye upon presentation.
His best-corrected acuity was 20/25 O.D. and 20/50 O.S. at distance and near. External examination findings were positive for periorbital edema and limited abduction O.S. There was no evidence of afferent pupillary defect.
The pertinent anterior segment findings are illustrated in the photograph.
Goldmann intraocular pressures measured 14mm Hg O.D. and 24mm Hg O.S. Dilated fundoscopy was within normal limits in both eyes.
How would you approach this case? Does this patient require any additional tests?
What is your diagnosis? How would you manage this patient? What is the likely prognosis
Additional testing may include checking the cornea and conjunctiva for staining, checking for symblepharon formation, and ruling out iritis. Additional procedures may include swabbing and lavaging the lids to remove debris.
The diagnosis in this case is contact dermatitis, presumably secondary to the chemical splash. The patient was treated O.S. with atropine 1% for cycloplegia, diphenhydramine 50mgs. p.o. b.i.d. for the medications antihistamine effects, polysporin ointment for prophylaxis of infection and copious artificial tears and frequent cold compresses for palliative purposes.
Two days later, the patient returned for follow up, and his symptoms were much improved. Visual acuity O.S. improved to 20/30. At this point, the left eye demonstrated a 95% return of ocular motility, grade 1 periorbital edema with normal eyelid position, noticeable reduction in palpebral and bulbar conjunctival edema, and markedly reduced corneal epitheliopathy. The intraocular pressures at this point measured 15mm Hg O.U.
The current medical regimen was continued. A topical steroid medication (prednisolone acetate 1% q.i.d. O.S.) was added for its anti-inflammatory effects.
When the patient returned in five days, the condition was completely resolved. The patient was dismissed with instructions to call or return immediately if the condition returned. He was scheduled a follow-up appointment in six months. There were no complications.
The thinness of the eyelid skin and conjunctiva makes them particularly delicate. The absence of firm adherences and the presence of loose subcutaneous tissues permits the accumulation of blood resulting from trauma and/or fluid resulting from an allergenic response.
Inflammation represents the bodys attempt to wall off areas of compromised tissue from healthy tissue, via the accumulation of fluid. The result is various levels of dolor (pain), rubor (redness), calor (heat), and tumor (swelling).1,2 Inflammation involves a complex sequence of events within tissues following initial exposure to an irritant.1,2 An inflammatory response is considered to be toxic when there is no previous record of exposure.1
Type IV hypersensitivity reactions, sometimes referred to as cell mediated hypersensitivity reactions, involve the T lymphocytes and lymphokines. Unlike the type I reaction, this reaction is classically delayed until sufficient antigens stimulate the chemical immune cascade. There is no direct IgE mediation to mast cell degranulation. That is why the reaction is not immediately observed.
Typically, patients with contact dermatitis present with a history of using or starting a new cosmetic, perfume, nail polish, clothing detergent, contact lens solution, ocular medication etc.1-23 The term medicamentosa keratoconjunctivitis is used to describe ocular reactions to ocular solutions and medications that produce a more substantial keratitis.24
The management of ocular contact dermatitis is primarily aimed at reducing symptomatology. 4,8,9,13,14,18-25 The easiest and most effective treatment for allergic conjunctivitis/contact dermatitis is elimination or avoidance of the offending allergen. The use of a cold compress, artificial tears, loose clothing ( if a covered area may be irritated by the vestments ) and ointments, cool, soothe and lubricate on an as-needed basis. Topical decongestants produce vasoconstriction, which reduces hyperemia, chemosis and other symptoms by retarding the release of the chemical mediators into the tissues from the blood stream. Topical antihistamines and oral antihistamines are also excellent therapies for acute signs and symptoms. Topical mast cell stabilizers should be used in seasonal or chronic cases involving the conjunctiva. The non-steroidal anti-inflammatory drugs may offer relief in moderate ocular cases with topical steroidal suspensions/solutions reserved for the most severe ocular presentations.
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