As part of Med-Challenger's Guideline Knowledge Check blog series, we sometimes like to address unusual cases where medical problems may become more prevalent given certain circumstances, like during a viral pandemic.  An increase in certain acute ophthalmic problems during the COVID-19 pandemic is a great example.  Try this case involving ophthalmic side effects of the coronavirus pandemic.  

Two adult males, ages 35 and 22 years old, present together via EMS to an emergency department at 2 am with intense eye pain and photophobia. Both also reported foreign body sensations in their eyes.

The pain started during the afternoon, when they were at their respective work-places, and became too intense to bear during the night. Nobody else at either workplace has developed symptoms. One patient works at a grocery store in the ordering department, the other patient works at a hospital as a lab technician.

Both deny trauma, or any other unusual exposures of their eyes, eg. to chemicals, welding, insects, or other irritating objects or events. The more severely affected patient wears corrective contact lenses at night for mild myopia; both deny any other ophthalmic history.

Both state that their vision is normally 20/20, but currently is slightly blurred. In the previous 5 days, both attended a party together with a friend who has since tested positive for SARS-CoV-2. Both patients deny COVID-19 symptoms.

An exam shows significant lid spasm, conjunctival injection, significant photophobia, and pronounced bilateral tearing in both patients. Both patients can read a hand-held vision card down to the 25/20 line.

Extraocular movements are intact; the pupils are constricted but reactive. Seidel test is negative and eye pressures are normal.

A slit lamp exam reveals conjunctival injection and punctate corneal lesions in all 4 eyes (see image); there is no hypopyon or bleeding noted; the retinas of all 4 eyes appear normal.

The lids are edematous, but show no signs of infection.

Question:

Answer Options:

Infectious keratitis due to aerosol-induced ophthalmic contact with SARS-CoV-2.

Inflammatory keratitis due to local auto-immune reaction to ophthalmic entry of SARS-CoV-2.

Infectious keratitis due to upward migration of nasopharyngeal SARS-CoV-2 into eyes rather than classic downward migration into oropharynx.

UV-keratitis; related to indoor exposure to UV-lights that are set up to eliminate SARS-CoV-2 from an indoor space.

With each update of national clinical practice guidelines, some recommendations change and many remain unchanged. Med-Challenger Guideline Knowledge Checks help you know both what is new and what has stayed the same in the most recent guidelines pertinent to each medical specialty.

Andrea Eberly, MD, FAAEM graduated from the David Geffen Medical School of Los Angeles (UCLA) and completed her residency in Emergency Medicine at the University Medical Center, Tucson, Arizona. After working as an attending physician in Tucson, she followed a recruiting call to the island of Guam, where she served in various roles, including as the director of the emergency department, the EMS Medical Director of Guam, and the Director of the 911 Call System. She has maintained her emergency medicine board certification through three cycles of American Board of Emergency Medicine Board Exams (last in 2014), all three with the help of Med-Challenger.