A 31-year-old woman comes to the office with a 5-day history of a red, painful right eye. She complains of photophobia, tearing, and decreased visual acuity and denies any history of trauma. She has had several similar episodes in the past. On examination, her visual acuity is 20/30 in the right eye, both pupils react normally, the conjunctiva is diffusely injected, and there is a watery discharge from the right eye. Fluorescein staining shows uptake in the right cornea, but the cornea is otherwise clear. The left eye is normal. The most likely cause of these findings is
A. acute angle closure glaucoma
B. allergic keratoconjunctivitis
C. bacterial conjunctivitis
D. herpes simplex virus keratitis
E. subconjunctival hemorrhage
Explanation:
The correct answer is D. Herpes simplex keratitis should be suspected in patients with recurrent symptoms of unilateral pain, redness, and photophobia in the presence of an epithelial staining defect. Under slit lamp biomicroscopy these staining defects often take on a "dendritic" appearance, but without a slit lamp they may appear as just fluoroscein uptake. These patients should be referred to an ophthalmologist for treatment. Never prescribe topical corticosteroids for patients with suspected herpes simplex keratitis.
Angle closure glaucoma (choice A) could be consistent with recurrent episodes, but not with this clinical presentation. Patients with angle closure glaucoma will present with poorly reactive pupils, marked decrease in visual acuity, and corneal edema making the cornea unclear.
Allergic diseases (choice B) are most commonly bilateral and are associated with a mucoid discharge and are less likely to cause pain, photophobia, and epithelial defects.
Bacterial conjunctivitis (choice C) rarely produces an epithelial defect, is often associated with copious mucoid discharge, and would not be expected to be recurrent.
Subconjunctival hemorrhage (choice E) is a benign clinical finding. In this case, it would not explain pain, photophobia, tearing, or decreased visual acuity.
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