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JAMA Ophthalmology Clinical Challenge
August 26, 2021

In Vivo Confocal Microscopy Evaluation of Microbial Keratitis

Author Affiliations
  • 1Department of Ophthalmology, Duke Eye Center, Duke University, Durham, North Carolina
JAMA Ophthalmol. Published online August 26, 2021. doi:10.1001/jamaophthalmol.2021.0948

A woman in her 20s with a history of daily soft contact lens (CL) wear was referred by her local ophthalmologist for a recalcitrant central corneal ulcer in her left eye. She had no history of eye trauma, did not sleep in her CLs, and stopped using CLs at symptom onset. Of note, she had recently been swimming in a freshwater lake prior to the onset of the ulcer. She was initially treated with topical besifloxacin and followed up daily. She appeared to improve clinically with resolution of her epithelial defect after 3 days, and topical loteprednol was added. Results of initial corneal cultures were negative. One week later, she presented with worsening pain and vision, which prompted referral to our cornea clinic where, 2 weeks after her initial presentation, her best-corrected visual acuity was 20/20 OD and 20/150 OS. Left-eye examination demonstrated diffuse microcystic corneal edema and stromal thickening with no Descemet membrane folds (Figure 1A). A 2 × 2-mm stromal opacity was noted paracentrally with no epithelial defects. The anterior chamber demonstrated 1+ cell. Intraocular pressure was 17 mm Hg OS. Corneal cultures for bacteria, fungi, and acanthamoeba were repeated, and in vivo confocal microscopy (IVCM) was performed on the stromal infiltrate (Figure 1B). After reviewing the IVCM images, what empirical treatment would you recommend while awaiting the results of the repeated corneal cultures?

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