A 56-year-old woman presented to our clinic with rapidly decreasing vision and increasing pain in her right eye over a 2-day period. The best corrected visual acuity was hand motion with her right eye and counting fingers with her left eye. Slit-lamp examination of her right eye revealed conjunctival xerosis, a 6×6mm2 central corneal epithelial defect with ring infiltration, and disciform stromal edema with Descemet membrane detachment (Fig. 1). The anterior chamber showed a severe reaction with 4+ cells. The left eye exhibited conjunctival keratinization and diffuse superficial punctate keratopathy. Both eyes showed a decrease in corneal sensation. The tentative diagnosis was xerophthalmia of both eyes and herpetic keratouveitis in the right eye, because the results of clinical imaging and the polymerase chain reaction test for herpes simplex virus-1 (HSV-1) was positive in the aqueous humor. An initial treatment consisted of 500mg of acyclovir administered intravenously every 12 hours because the patient had an oral ulcer and was thus incapable of swallowing large tablets. Tobramycin (3mg/mL) eye drops and artificial tears (Vidisic gel, Dr. Gerhard Mann Chem.-Pharm. Berlin, Germany) were administered four times a day in both eyes. On the second day of hospitalization, the anterior chamber reaction had worsened in her right eye and a 1×1mm2 corneal epithelial defect appeared in the left eye (Fig. 2). Dexamethasone 1.5mg (5mg/1mL) was therefore injected into the subconjunctival space of the right eye. The reaction of the anterior chamber was eased after this igf ir procedure.
Unfortunately, on the evening of the fourth day, the density of the ring infiltrate and hypopyon increased in the right eye. A 2×2mm2 paracentral corneal ulceration with minimal hypopyon was also noted in the left eye. Furthermore, a purulent discharge developed the next morning, and the condition of both eyes worsened (Fig. 3). A superimposed bacterial infection in both eyes was thus suspected and an hourly treatment of topical fortified gentamicin (15mg/mL), alternating with cefazolin (50mg/mL) every hour, was started. Additionally, 1g of cefazolin was administered every 8 hours and 120mg of gentamicin twice a day, both intravenously. Smear tests and bacterial cultures proved that both eyes were infected with Pseudomonas aeruginosa.
Meanwhile, we conducted a systemic survey on the patient. The biochemical analysis on her blood sample showed that the serum albumin was 3.4g/dL (normal range 3.5∼5.2g/dL), total protein was 5.9g/dL (normal range 6.2∼8.3g/dL), cholesterol was 91mg/dL (normal range 130∼200mg/dL), and triglyceride was 32mg/dL (normal range 35∼200mg/dL). No remarkable result was found on the hematologic, immunologic, and rheumatologic evaluations, except for mild anemia (hemoglobin 10.1g/dL, hematocrit 31.5%). Abdominal sonography showed that her liver and kidneys were normal except for a gallbladder polyp. On reviewing her medical history, we found that the patient had difficulty in eating solid food because she had biting pain with tooth mobility for months and had a long followed strict vegetarian diet, she also disliked carrots, sweet potatoes, pumpkins, and asparagus, and was restricted from eggs and milk. No major surgery or medical disease in previous years was mentioned, except for a history of dry eye syndrome. The patient had been informed of the diagnosis of vitamin A deficiency due to conjunctival xerosis (Fig. 4) 2 months ago. Artificial tears and vitamin A ointment had been prescribed. The patient was asked to take vitamin A pills and more vitamin A containing food such as papaya, spinach, etc. However, she did not seem to follow these suggestions. Her weight was 38kg and height was 150cm. Her skin was scaling and dry. This general appearance in conjunction with the aforementioned ocular signs strongly suggested that the patient had severe vitamin A deficiency and malnutrition. As such, she was placed on a high-protein diet as monitored by a nutritionist and asked to ingest multivitamin pills, including 5,000IU of vitamin A daily.