A middle-aged man presented with a 4x4mm corneal ulcer in his left eye caused by plant trauma 4 days prior. He was given topical natamycin, oral itraconazole, and moxifloxacin. After 2 days the ulcer size reduced to 2.5x3mm with continued topical treatments and the addition of tobramycin and gatifloxacin. By the 4th visit, the cornea began melting and doxycycline was added orally. At the 5th visit, the ulcer was reduced to 1.5x2mm with improved injection but persistent edema, and he remains under follow up.

1. Infectious Keratitis
A systematic approach
Prepared by: Ahmed M. Abdelfattah
Presented by: Ahmed M. Abdeltawab

2. 1st Visit 11th Oct 21
• middle-aged man
• 4 days earlier, trauma OS ( Plant origin)
• VA : CF @ 25cm.
• Eyelid Edema
• SLE: Conjunctival injection & a corneal ulcer (4x4mm) with surrounding dense
infiltration and corneal edema with AC reaction .
• No KPs or changes in IOP were noted.
• Denied Contact Lens wear.
• No other relevant history reported by the patient.

3. Slit Lamp image

4. • Initial diagnosis: query fungal ulcer, sent for C&S
• Empirical treatment:
• Natamycin ED q1hr
• Oral Itraconazole BID
• Moxifloxacin ED q1hr
• Follow up in 3 days.

5. 2 days later

6. 13th Oct 21
Culture results

7. Culture

8. 2nd Visit
14th Oct 21
Follow up
• Eyelid edema: improved
• Conjunctival injection persistent
• Ulcer size (4x4mm)
• Corneal infiltration ++
• Corneal edema +
• AC : quiet, no reaction

9. Slit Lamp Image 2nd Visit

10. Treatment:
• Natamycin ED q1hr
• Oral Itraconazole BID
• Gatifloxacin ED q1hr (introduced)
• Tobramycin EO 5 times/day (introduced)
• Follow up in 5 days

11. 3rd Visit
19th Oct 2021
Follow up 2
• VA: improved to 1/60
• Conjunctival injection persistent
• Ulcer size (2.5x3mm)
• Corneal infiltration +
• Corneal edema +
• AC: quiet, no reaction
• Follow up in 1 week

12. Slit Lamp Image 3rd Visit

13. Treatment:
• Natamycin ED q1hr
• Gatifloxacin ED q1hr
• Tobramycin EO once daily (reduced application)
• Tobramycin ED 5 times/day (introduced)
• Cornergel TID (introduced)
• Follow up in 5 days

14. 26th Oct 21
4th Visit
Follow up 3
• VA : improved to 1.5/60
• Conjunctival injection persistent
• Ulcer size (2.5x2.5mm)
• Corneal infiltration +
• Corneal edema +
• AC: quiet, no reaction

15. Slit Lamp Image 4th Visit
However..
The cornea was melting !!!

16. Treatment:
• Natamycin ED QID (reduced application)
• Gatifloxacin ED q2hr (reduced application)
• Tobramycin EO once daily
• Tobramycin ED TID (reduced application)
• Oral Doxycycline BID ( introduced )
• Oral vitamin C TID
• Systane ED q2hr
• Follow up in 4 days

17. 5th Visit
30 Oct 2021
Follow up 4
• VA: improved to 2/60
• Conjunctival injection improved
• Ulcer size (1.5x2mm)
• No corneal infiltration
• Corneal opacity (ppt)
• Corneal edema +

18. Slit Lamp Image 5th Visit

19. Treatment:
• Gatifloxacin ED 5 times/day (reduced application)
• Tobramycin ED TID
• Oral Doxycycline BID
• Oral vitamin C BID
• Systane ED q2hr

20. Currently…..
Still under follow up

21. Thank You