Contact Lens Wearer With a Painful Red Eye Who Wants Numbing Drops

This is a same-day urgent ophthalmic problem, not a routine contact lens check. A painful red eye in an overnight soft lens wearer with an infiltrate, epithelial defect, decreased vision, and anterior chamber reaction is a corneal ulcer until proven otherwise. The most likely organism is Pseudomonas aeruginosa, classically associated with overnight hydrogel wear and capable of rapid melting. The differential also includes Acanthamoeba (exposure to tap water, homemade saline, swimming, or a case rinsed with water), herpes simplex keratitis (prior episodes, dendritic staining, reduced corneal sensation), fungal keratitis (organic trauma), and sterile infiltrates, which are usually smaller, peripheral, and less painful.

Immediate plan: notify the physician now; the patient should be worked in today, not at 4 pm if any earlier slot can be created, and not sent home to return tomorrow. Do not prescribe or dispense topical antibiotics, do not pressure-patch, and do not give her anesthetic drops to take home. Retrieve the lens and case for possible culture; instruct her not to wear any lenses in either eye until cleared. Keep her comfortable, minimize unnecessary bright light, and document the infiltrate size, location, and overlying defect.

Safe and useful: entering visual acuity with her current correction (pinhole only if it does not cause undue pain), pupils, external and motility examination, and careful slit-lamp documentation of the defect with fluorescein and cobalt blue or a wratten filter. Measure and record the defect's dimensions and location, the infiltrate's depth and distance from the visual axis, and the amount of anterior chamber reaction. Check for hypopyon. Ask about water exposure, case hygiene, and prior corneal disease.

Avoid: applanation tonometry with a reusable prism over an infected, epithelial-defective cornea, because of cross-contamination and mechanical trauma; use a disposable tip or Tonopen cover only if the physician specifically needs the pressure, or defer it. Do not press on the globe if you suspect impending perforation or a melt. Do not instill a topical anesthetic for comfort and then let her leave; anesthetic is for examination procedures only, never for outpatient dispensing, because it is toxic to the epithelium and masks worsening disease. Do not start antibiotics or steroids on your own, and do not patch the eye. Fluorescein itself is appropriate and does not prevent later culture.

Tell her clearly and without alarm that this is a serious corneal infection and that she needs to be seen today; waiting until tomorrow risks worse scarring and vision loss. She should not drive herself if she is photophobic and monocular-blurred, so arrange a ride or wait for the physician's advice. She must not rub the eye, must not wear either contact lens, and must not use any old antibiotic or steroid drops from home. Discard the lens and the case, or at minimum bring them for culture; do not rinse the case with tap water. Explain that the numbing drop is only for examination and cannot be sent home because repeated use damages the cornea and hides worsening pain.

Record: time of arrival, entering acuity, the exact slit-lamp description with a sketch if your clinic uses one, lens type and wear schedule including overnight use, the fact that the lens and case were retained, the patient's request for anesthetic and your response, the physician notification time, and the education given. Note the follow-up plan and warning signs: increasing pain, worsening vision, discharge, or a white spot enlarging. Arrange a 24-hour recheck as the physician directs.