Atypical Case of Corneal Abrasion and Herpes Keratitis

April 12, 2009

A 62 year old woman with no significant history told me she struck her right eye with her finger or mascara brush the other day. On exam, there was a large stellate abrasion, but- there was significant folds in the inferior half of the cornea, and a 1+ A.C. reaction. Furthermore, the endothelium had a scalloped appearance. I violated Occam’s razor- the simplest answer/diagnosis (or, in other words, the answer that requires one diagnosis as opposed to two) is the best one and almost always the correct one. I gave her two diagnoses- I figured the scalloped endothelium was posterior polymorphous dystrophy in addition to the abrasion. I gave her Zymar QID. Later that evening, she called me and told me her vision was much worse. I saw her the following day, and her entire cornea was now steamy (though the abrasion was smaller). Now it was clear to me what she had- atypical¬† Herpes. In fact, in hindsight, her relative lack of severe pain on presentation (it was a verly large abrasion) made more of an impression on me and confirmed in my mind that it was Herpes. I started her on Viroptic Q2h, and in 48 hours, the cornea was almost perfectly clear.

So- violate Occam’s Razor at your own peril.




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