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    Management of drug-induced cicatricial conjunctivitis and dry eye

    Ophthalmology Times Resident Writer’s Award Program

    A 65-year-old male with long-standing ocular surface disease presents for evaluation of decreased vision and pain of the left eye for one week. The patient has an extensive ocular history, including congenital cataracts, bilateral cataract extraction and later secondary placement of anterior chamber intraocular lenses, then subsequent development of bilateral glaucoma and cicatricial conjunctivitis resulting in bilateral limbal stem cell deficiency (LSCD), recurrent epithelial defects, dry eye disease, fornix foreshortening, trichiasis, and entropion. His glaucoma has been managed at an outside facility with maximum topical medical therapy for many years. His bilateral upper eyelid entropion was repaired with oral mucous membrane graft approximately one year prior to presentation. He wears bandage contact lenses and has been using moxifloxicin hydrochloride ophthalmic solution 0.5% (Vigamox®, Alcon, Fort Worth, TX) twice a day and loteprednol etabonate ophthalmic suspension 0.5% (Lotemax®, Bausch+Lomb, Bridgewater, NJ) four times a day in both eyes for at least two years for his severe ocular surface disease. Most recently, he has had to switch from moxifloxicin to polymyxin B sulfate trimethoprim due to a change in his insurance coverage. He was seen by his outside ophthalmologist and referred to the emergency department given concern for severe dry eye disease complicated by a corneal ulcer in the left eye.

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    Examination

    On initial evaluation, the patient had a best-corrected visual acuity of 20/70 with pinhole vision of 20/60 in the right eye, and counting fingers in the left eye. Intraocular pressures (IOP) were 14 bilaterally. External examination showed extensive chronic inflammatory changes of the eyelids bilaterally, including severe induration, thickening, and notching of the eyelid margins, meibomian gland dysfunction and trichiasis. He had diffuse conjunctival injection, greater in the left eye, with forniceal foreshortening in both eyes. The cornea in the right eye had neovascularization 3-mm onto the cornea superiorly, diffuse faint subepithelial haze, and a whorling pattern of the epithelium with scattered punctate epithelial defects. The cornea in the left eye showed a central epithelial defect with associated infiltrate consistent with a corneal ulcer as well as superior fibrovascular pannus 3-mm onto the cornea and band keratopathy temporally. The anterior chamber in the left eye had a hypopyon and there were bilateral anterior chamber intraocular lenses. There was a poor view to the posterior pole in both eyes due to the severe ocular surface disease, but B-scan ultrasound was normal bilaterally.

    Discussion and diagnosis

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