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JAMA Ophthalmology Clinical Challenge
June 2014

Man With Blurry Vision

Author Affiliations
  • 1Department of Ophthalmology, University of Illinois at Chicago
JAMA Ophthalmol. 2014;132(6):771-772. doi:10.1001/jamaophthalmol.2014.203

A 53-year-old man presented with progressively worsening blurry vision of the left eye. The patient reported redness in his eye for 2 days. He denied pain, itchiness, or recent ocular trauma. He had a distant history of contact lens wear but terminated use owing to recurrent corneal abrasions. His medical history was significant for uncontrolled type 2 diabetes mellitus, leading to bilateral below-the-knee amputations, and osteomyelitis. The patient was unemployed and denied cigarette smoking, alcohol use, or drug use. Current medications included insulin, nasal spray, and aspirin. Review of systems was positive for stiff joints of the hands and back pain. The patient reported that results from a workup for Crohn disease were negative. On examination, uncorrected visual acuity was 20/40 in the right eye and 20/100 in the left eye. Findings from Schirmer testing without anesthesia for 2 minutes were 20 mm OD and 15 mm OS. Corneal sensation was bilaterally decreased to a level of 2/4. There were inferior corneal epithelial defects, with significant corneal thinning bilaterally, and an inferonasal Descemetocele of the right eye. The anterior chambers possessed 3 to 4+ cells, with bilateral hypopyons (Figure). Serology was sent owing to concern regarding the patient’s joint pain, need for a Crohn disease workup, and presence of bilateral corneal thinning with anterior uveitis. Significant results included an elevated rheumatoid factor of 27 IU/mL (normal, 0-14 IU/mL), while all other laboratory results were within normal limits. Results from corneal cultures were positive for pansensitive coagulase-negative Staphylococcus, which was likely a contaminant from the eyelids.

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