This Week's Eye-Openers

JAMA Ophthalmology

When corneal opacities point beyond the eye

Progressive bilateral interstitial keratitis with sensory and cutaneous findings should prompt consideration of a systemic diagnosis. A 31-year-old woman from Guam presented with progressive bilateral blurred vision, photophobia, and corneal opacities. Symptoms began in the right eye in 2011 and later developed in the left eye in 2021. She denied trauma, herpes infection, atopy, sexually transmitted infections, and tuberculosis exposure. Topical prednisolone had provided no improvement.

Visual acuity was counting fingers OD and 20/80 OS. The right cornea demonstrated diffuse haze, a large inferior stromal opacity, and 360° superficial and deep stromal neovascularization. The left eye had focal punctate stromal opacities and more limited neovascularization. Corneal sensation was reduced bilaterally. Examination also revealed progressive facial skin thickening, loss of facial hair, facial sagging, and a flattened nasal bridge.

The combination of bilateral interstitial keratitis and systemic cutaneous findings raised concern for Hansen disease. Dermatologic examination showed violaceous papulonodular lesions and impaired temperature and pressure sensation in both upper extremities. Skin biopsy demonstrated nodular granulomatous dermatitis with numerous acid-fast bacilli, supporting Mycobacterium leprae infection. The patient began multidrug antimicrobial therapy. At one month, corneal clarity and left-eye vision improved to 20/30, while the right eye remained stable. This case emphasizes the importance of recognizing systemic clues in atypical presentations of keratitis.

A 42-year-old woman with no past ocular history presents with worsening blurry vision, irritation, and redness in her right eye two weeks after sodium hydroxide drain cleaner splashed into her eye. At the time of the injury, she irrigated her eye with tap water for approximately 10 minutes. She did not seek medical care and has only been using artificial tears since. 

Her visual acuity is 20/200 OD and 20/20 OS. On examination of the right eye, there is conjunctival injection, perilimbal ischemia, diffuse corneal haze, and a persistent corneal epithelial defect. The intraocular pressure is 28 mmHg. The pH of the ocular surface is now physiologic, the fornices have been cleared of any remaining material, and the B-scan ultrasonography shows that the retina is attached.

Which of the following best describes the primary mechanism of this patient’s injury?

A. Coagulation of tissue proteins, forming a barrier that limits deeper chemical penetration

B. Saponification of cell membrane lipids causing rapid penetration and liquefactive necrosis

C. Immune complex deposition within the corneal stroma, leading to complement-mediated inflammation

D. Thermal denaturation of superficial epithelial proteins

E. Hyperosmotic injury causing epithelial dehydration and cellular shrinkage

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