The Red Eye on the Surgical Ward
A 72-year-old man is on the surgical ward on day 4 after an emergency laparotomy for perforated diverticulitis. He is on intravenous piperacillin-tazobactam and has a central line. Overnight he develops a painful red right eye with reduced vision and a purulent discharge. The surgical FY2 has diagnosed 'conjunctivitis' and started topical chloramphenicol. The nurse is concerned because the eye looks worse this morning and asks you to review. On examination, visual acuity is 6/60 right eye (previously 6/9), there is marked lid swelling, diffuse conjunctival injection with chemosis, and the cornea has a hazy area with a small epithelial defect; there is a hypopyon visible at the inferior limbus. He is systemically stable but mildly confused.
1. Why is the working diagnosis of conjunctivitis dangerous here, and what is your differential?
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The features are not those of conjunctivitis: pain, marked visual loss (6/9 → 6/60), lid swelling, chemosis, a corneal epithelial defect with haze, and a hypopyon all point to a serious anterior segment infection. Calling this conjunctivitis and treating with chloramphenicol risks corneal perforation, endophthalmitis, and permanent blindness.
The leading differential is microbial keratitis, possibly with early endophthalmitis given the hypopyon and profound visual loss. Risk factors here are potent: hospitalisation, broad-spectrum antibiotics (selecting resistant organisms), a central line and possible bacteraemia, and his mild confusion. Organisms to consider include Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus species, and Gram-negatives; in a hospitalised, antibiotic-exposed patient, resistant organisms are a real concern.
The judgement is that this is an ophthalmological emergency requiring same-day specialist review, not a ward-managed minor infection.
2. Outline your immediate management while awaiting ophthalmology review.
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- Escalate now: contact ophthalmology urgently (same day, ideally immediately) - this needs slit-lamp assessment, corneal scraping for microscopy and culture, and a decision on intensive topical therapy.
- Do not delay empiric treatment if ophthalmology cannot attend promptly: start intensive topical antibiotics (e.g. fortified preparations covering Gram-positive and Gram-negative organisms, given frequently, day and night) per local protocol, and stop the chloramphenicol, which is inadequate.
- Take swabs/corneal scrapings before antibiotics if feasible, but do not let this delay treatment.
- Review the systemic picture: the hypopyon and confusion raise the question of endophthalmitis with a systemic source (central line sepsis, bacteraemia). Take blood cultures, review the line, and consider whether the central line needs removal.
- Protect the eye: shield, avoid pressure, ensure no contact lens, and manage pain.
- Document and hand over clearly so the eye is reviewed repeatedly, not left until the next ward round.
3. What systemic factors on this ward make him particularly vulnerable, and how would you address them?
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He is post-major abdominal surgery, on broad-spectrum intravenous antibiotics, with a central line, and mildly confused - a combination that predisposes to nosocomial, often resistant, ocular infection and to haematogenous spread (endophthalmitis).
Addressing them:
- Antibiotic stewardship: review whether piperacillin-tazobactam is still appropriate and whether the spectrum covers likely ocular pathogens; liaise with microbiology.
- Central line review: the line is a potential source of bacteraemia seeding the eye - assess for infection and consider removal, with blood cultures.
- Delirium/confusion: this may be sepsis-related or a marker of systemic deterioration; it also means he may not report eye symptoms early, so nursing staff must be asked to watch for eye pain, redness, or discharge.
- General care: analgesia, glycaemic control if diabetic, and nutrition all affect healing and infection risk.
The key judgement is to treat the eye as a systemic warning sign, not an isolated ward nuisance, and to coordinate surgical, microbiology, and ophthalmology teams.