Suspected microbial keratitis at a polyclinic with no ophthalmologist, and a patient who refuses referral

Differential, by probability and by danger.

1. Bacterial microbial keratitis, likely Pseudomonas - extended/overnight soft lens wear plus sea water, a central epithelial defect, dense stromal infiltrate, hypopyon, acuity down to 6/24.
2. Acanthamoeba keratitis - sea-water exposure fits; often more indolent with pain out of proportion and a ring infiltrate later. It cannot be excluded on day two.
3. Fungal keratitis - less likely with this history but possible after organic or water exposure.
4. Herpes simplex epithelial keratitis - usually a dendritic defect, not a dense stromal infiltrate with hypopyon.
5. Sterile infiltrative keratitis or CLARE - typically smaller, peripheral, with an intact epithelium. This does not fit.

Why it is sight-threatening. A central 3.5 mm infiltrate with hypopyon means organisms and inflammatory cells sit in the visual axis; corneal melting and perforation can occur within 24–48 hours, and final acuity is strongly time-dependent. A week's delay is not a plan.

Immediate actions here.

• Do not patch - a closed, warm eye conceals deterioration.
• Do not use a topical steroid or a topical anaesthetic.
• Do not hand over a bottle of drops and discharge him.
• Telephone the eye hospital emergency department, describe the findings, and send him today with a written note: acuity, defect size and position, infiltrate and hypopyon size, lens and water history, your name and a contact number. Arrange transport rather than a 25 km bus journey if at all possible.
• If transport will be delayed, start intensive topical fluoroquinolone (for example moxifloxacin 0.5%) every 15–30 minutes while it is arranged, record the time of the first dose, and tell the hospital - they will want a corneal scrape and culture before or alongside definitive therapy.

Capacity and consent. He is an adult with capacity. He may refuse; my duty is to make the refusal genuinely informed, to remove the practical obstacles, and to document it properly - not to override him.

The conversation. Without dramatising, state the risk in plain terms: 'This is an infection inside the clear front of your eye. Without proper treatment within a day it can scar, perforate, or permanently reduce the sight in that eye. Drops and a patch will not fix it, and next week is too late.'

Then solve his problem rather than argue. The eye hospital runs a 24-hour emergency service; he can sit the examination tomorrow and attend tonight or immediately afterwards; ask whether a relative can drive him; telephone the hospital so he is expected and does not sit waiting. Offer the safest fallback if he still refuses: written advice, a definite appointment, and a telephone check within 24 hours, with instructions to return immediately if pain or vision worsens.

Escalate. Inform the duty medical officer or clinical supervisor and record that you did so - in an MOH facility the refusal of an emergency referral is not something one clinician should carry alone.

Documentation. Findings; the diagnosis discussed and the risks in the patient's own words where possible; the options offered, including transport; his refusal; the escalation; and a witness signature. Give him a copy of the written advice. A thin record is what turns a poor outcome into a professional complaint; a complete one shows the standard of care was met.

Clinic infection control after this patient.

• Hand hygiene before and after; gloves for contact with secretions; eye protection if there is any splash risk.
• Wipe the slit lamp chin rest, forehead band and joystick with 70% alcohol or an approved disinfectant wipe after the examination, allowing the stated contact time.
• Never let a drop bottle tip touch lashes or cornea; if it does, discard the bottle. Use single-use fluorescein strips, one per patient, and dispose of them as clinical waste.
• Any tonometer prism used must be disinfected to policy or be single-use; nothing is passed between patients without decontamination.
• Clean and disinfect any trial frame or trial lens that was handled, and keep to the clinic's disinfection record.

Advice on lens wear.

• Stop all lens wear until the ophthalmologist confirms the cornea is healed - usually several weeks - and a new fit has been checked.
• Discard the current pair and the lens case. Do not try to disinfect them and reuse them.
• Never sleep or nap in lenses; that is the single biggest risk factor in his history.
• Never swim, shower or use a hot tub in lenses, because of Acanthamoeba risk.
• Wash and dry hands before handling lenses; fresh solution every time, never top up; replace the case regularly.
• Keep spectacles as a backup so that a lost or damaged lens never forces him back into an unsafe habit.

Record that this counselling was given and provide it in writing.