Filamentary Keratitis as a Presenting Sign

Brett W. Neal, OD, Case Series Editor: Jean Marie Pagani, OD

February 05, 2015

Clinical Presentation

A 73-year-old black woman presented as an emergency with a chief complaint of a red irritated right eye (OD) for 1 week.

Her medical history was significant for arthritis, hypertension, and diabetes. The patient was unsure of her systemic medications. She reports a history of intermittent bilateral (OU) red eyes, which have previously been treated with cyclosporine (Restasis®) twice daily, acetylcysteine (Mucomyst®) four times daily, and lubricant eye drops (Systane®) four times daily OU.

On examination, her best-corrected visual acuity (BCVA) was 20/60 OD and 20/20 left eye (OS). A slit lamp examination revealed significant Meibomian gland dysfunction OU with frothing OD > OS, confluent superficial punctate keratitis (SPK) OD, scattered SPK OS, corneal filaments OD > OS, and conjunctival injection OD. No anterior chamber reaction was present in either eye.

The patient was tentatively diagnosed with filamentary keratitis, OD > OS. The filaments were removed in the office, and inferior punctal plugs were inserted OU. She was given prescriptions for loteprednol drops (Lotemax®), to be administered twice daily OD, and Restasis twice daily OU.

She returned 5 days later, complaining that she was now unable to open her right eye and was experiencing increased pain in that eye.

Her BCVA was 20/200 OD and 20/20 OS. A slit lamp examination revealed 3 mm ptosis OD, 1+ lid edema OD, 2+ corneal edema OD, an epithelial defect inferiorly OD with 10% corneal ulceration, 3+ conjunctival injection OD, corneal filaments OU, 1+ conjunctival injection OS, and scattered SPK OS.

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