Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.
Background
A 47-year-old man who has been living with HIV infection since 1995 developed a foreign-body sensation in his right eye. He is on antiretroviral therapy (ART), his HIV viral load is undetectable, and his CD4 lymphocyte count is in the range of 600 cells/mm3 (reference range, 500-1500 cells/mm3). He is adherent to his ART regimen and reports no missed doses. He lives with his boyfriend with whom he is sexually active.
The foreign-body sensation developed in the patient's right eye while he was doing laundry at work. He attempted to relieve the presumed foreign body by using cleaning rags that he found in the laundry area. He does not recall ever seeing any foreign body in his right eye and has also not experienced any recent trauma to the eye. He initially presented to an emergency department and underwent fluorescein staining, which did not reveal a foreign body in the right eye. He was instructed to follow up with an ophthalmologist.
The follow-up ophthalmologic examination showed the pupils to be equal, round, and reactive to light bilaterally and did not reveal any corneal haziness or foreign body. The fluid in the anterior chamber was clear without sediment or blood; however, conjunctivitis was noted in the right eye. Given his exposure to cleaning and laundry chemicals at work, he received a diagnosis of a corneal chemical injury. He was treated with levofloxacin 500 mg orally daily and tobramycin ophthalmic 0.3% solution, two drops to the right eye every 4 hours.
Swelling of the right eye developed and progressed to the extent that the eye was swollen shut. The patient also had thick yellow discharge from the eye. His visual acuity decreased to the point that he was only able to perceive light with the right eye. He subsequently presented to an ophthalmologist at an academic medical center. Normal ocular pressures were documented, and a diagnosis of corneal chemical injury was made. He was treated with moxifloxacin ophthalmic 0.5% solution, one drop to the right eye twice daily. After he had used the ophthalmic solution for 4 days, his right eye symptoms improved and he self-discontinued the solution. His symptoms recurred and then worsened.
Ten days after the onset of his ocular symptoms, the patient presented to the ophthalmologist at the academic medical center for reevaluation. His right eye had again swollen shut and had thick yellow discharge. His visual acuity in the eye had decreased to the point that he was only able to perceive light. He also complained of a right-sided headache that he described as a "migraine." He did not have fever or chills.
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Cite this: D. Matthew Shoemaker. Sexually Active Man With Foreign-Body Feeling, Eye Discharge - Medscape - Mar 09, 2022.
