MKSAP: 68-year-old man with a sensation of dryness in his eyes

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 68-year-old man is evaluated for a 6-month history of a sensation of dryness in his eyes. He notes that it feels as though there is sand in his eyes.

On physical examination, the eyes are red, and trichiasis (ingrown eyelashes) and symblepharon (adhesions of the eyelid to the globe) formation is noted.

Which of the following is the most appropriate next step in management?

A) Conjunctival biopsy
B) Intravenous acyclovir
C) Prednisone and oral cyclophosphamide
D) Topical gentamicin 0.3%

MKSAP Answer and Critique

The correct answer is A) Conjunctival biopsy. This item is available to MKSAP 15 subscribers as item 19 in the Dermatology section. More information about MKSAP 15 is available online.

This patient probably has ocular cicatricial pemphigoid based upon the history of dryness of the eyes and evidence of conjunctival scarring (trichiasis and symblepharon). Ocular pemphigoid can result from several immunologic phenomena, including linear IgA deposition, linear IgG deposition resembling bullous pemphigoid, or linear IgG deposition resembling epidermolysis bullosa acquisita. This disorder can be sight-threatening and, therefore, warrants accurate diagnosis with biopsy and appropriate histopathologic studies. Biopsy of the conjunctiva will reveal subepithelial separation below the basement membrane, and direct immunofluorescence will reveal linear deposition of IgG and C3 at the basement membrane zone. Once the diagnosis is confirmed, aggressive management with corticosteroids and cyclophosphamide is indicated. However, treatment with prednisone and cyclophosphamide should wait until confirmation of the diagnosis.

Herpes zoster ophthalmicus is a complication of varicella-zoster virus infection involving the ophthalmic division of the fifth cranial nerve. Most patients with herpes zoster ophthalmicus will experience headache and fever associated with pain or hypesthesia in the affected eye and forehead. With outbreak of the characteristic cutaneous vesicles, patients typically develop hyperemic conjunctivitis. Severely ill patients are often treated with intravenous acyclovir, but less ill patients may be successfully treated with oral valacyclovir or famciclovir. In the absence of the typical vesicular eruption of herpes zoster, there is no indication for intravenous acyclovir.

Bacterial conjunctivitis is caused by a range of gram-positive and gram-negative organisms and is characterized by presentation in one eye, but this condition often spreads to involve the other eye and is associated with purulent discharge. Empiric treatment with broad-spectrum topical antibiotics is indicated in patients with bacterial conjunctivitis. The patient’s 6-month history of ocular symptoms is not compatible with an acute bacterial conjunctivitis, and treatment with a topical antibiotic should not take precedence over a conjunctival biopsy.

Key Point

  • Ocular cicatricial pemphigoid is sight-threatening and warrants accurate diagnosis with biopsy and appropriate histopathologic studies, as well as aggressive management with corticosteroids and cyclophosphamide.

Learn more about ACP’s MKSAP 15.

– This content is excerpted from MKSAP 15 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 15 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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