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JAMA Ophthalmology Clinical Challenge
December 30, 2020

A Nonhealing Epithelial Defect in a Patient Experiencing Alcohol Use Disorder

Author Affiliations
  • 1Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Ophthalmol. Published online December 30, 2020. doi:10.1001/jamaophthalmol.2020.4651

A 50-year-old man with a history of type 2 diabetes, hypertension, heroin use, and alcohol use disorder presented with a new epithelial defect in the setting of a healing right corneal ulcer. Six days prior, he had presented with an inferior stromal infiltrate with an overlying epithelial defect, diffuse corneal edema, and a small hypopyon with no hemorrhage in the anterior chamber (Figure 1A). He also had patchy iris hemorrhages with no transillumination defects and areas of conjunctival ulceration nasally and temporally. He denied contact lens use. Given these findings, a presumed herpes zoster sine herpete1 with secondary bacterial infection was suspected. Treatment with hourly topical vancomycin at 14 mg/mL and tobramycin at 25 mg/mL, as well as 1000 mg of oral valacyclovir 3 times a day, was initiated. Corneal cultures grew Streptococcus pneumonia. He initially responded well with improvement of the stromal infiltrate and overlying epithelial defect. However, on day 6 of treatment, he had a new larger epithelial defect and subepithelial bullae in an adjacent location but no infiltrate. While evaluating the new defect, the patient was also noted to have dull conjunctival reflexes and bulbar conjunctival lesions in both eyes (Figure 1B). Additionally, both eyes had patchy interpalpebral results on lissamine green staining of the conjunctiva and clinically significant punctate epithelial erosions of the cornea with fluorescein staining.

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