We present the case of a 45-year-old man who presented with bilateral ocular pain, intense photophobia and decreased visual acuity (VA). A fortnight earlier he had been diagnosed with keratoconjunctivitis, probably adenoviral, and was being treated with tobramycin eye drops (Tobrex, Alcon Cusi, Barcelona) and cyclopentolate hydrochloride (Cicloplegic, Llorens, Barcelona). She reported itching, photophobia and redness for 3 months, concomitant with asthenia, cachexia and a weight loss of 16 kilograms (kg).
His personal history included chronic alcoholic pancreatitis, non-insulin-dependent diabetes mellitus, smoking and a cholecystostomy with percutaneous shunt performed 11 months earlier. Ophthalmological history includes excision of a pterygium in the OD associated with betatherapy 5 years earlier and a posterior sclerocorneal lamellar lamellar graft due to trauma.
On examination, the patient had finger-counting VA (cd) at 3 metres in the OD and light perception and projection in the OI. The OD showed intense vascular injection, microcystic epithelial oedema, superior peripheral ulcerative keratitis (PUC), 4-cross tyndall and posterior synechia, with intraocular pressure (IOP) of 16 mmHg and a non-relevant fundus oculi (FO). The OI shows a very severe injection of conjunctival, ciliary and episcleral vascularisation, 360º pannus, pterygium, a central corneal ulcer with stromal necrosis, hyphema level occupying half of the anterior chamber (AC) and 360º posterior synechiae, with IOP of 26 mmHg and unexplorable FO. Corneal sensitivity is normal in both eyes (AO).
He was admitted to the hospital to start a study and treatment with oral prednisone 1 mg/kg/day (Dacortin 30 mg, Merck, Barcelona), oral doxycycline 100 mg/12 h (Vibracina 100, Pfizer, Madrid), atropine eye drops 1%/8 h (Atropine 1%, Alcon Cusí), tobramycin and dexamethasone/4 h (Tobradex, Alcon Cusí) and carmellose sodium 0.5/h (Viscofresh 0.5%, Allergan, Madrid).
Seven days later the hyphema disappeared, but a level of hypopyon appeared in the OI, so vancomycin eye drops at a concentration of 50 mg/ml/h (Diatracin Injectable 500 mg, Lilly and Dista, Madrid), and gentamicin 14 mg/ml/h (Gevramycin 40 mg injectable, Schering-Plough, Madrid), with negative corneal cultures for bacteria, fungi, viruses and parasites, were associated. A diagnostic-therapeutic upper conjunctival excision OD ruled out vasculitic lesions or the presence of herpes simplex virus (HSV 1 and 2) by immunohistochemistry, showing intense acanthosis and an absence of goblet cells.
Systemic examination ruled out any signs of rheumatic involvement, with negative serology for infectious diseases and markers of rheumatic diseases and vasculitis, except for elevated C-reactive protein and erythrocyte sedimentation rate. Laboratory tests revealed macrocytic and hypochromic anaemia, a pattern of severe lipoprotein malnutrition, hyperglycaemia and elevated liver enzymes. Malabsorption studies revealed mild malabsorption and decreased fat-soluble vitamins [vitamin A: 0.24 mg/ml (micrograms/millilitre) (N:0.4-0.8)], and vitamin A carrier proteins [retinol binding protein (RBP) and prealbumin].
Chest X-ray, cranial and thoraco-abdominal computed tomography (CT) were normal. The orbital CT scan showed mucosal thickening of the right maxillary sinus with normal ENT examination. Ocular ultrasound ruled out vitreo-retinal involvement of the OI.
A diagnosis of calorie and protein malnutrition with vitamin A deficiency was made, and treatment was started with a high protein and high calorie diet without sugar, pancreatic enzymes and oral vitamins.
The evolution was favourable, with resolution of the AO picture after 2 months and a VA of 1 OD and of cd to 1 m OI. The OI presents a central leukoma limited inferiorly by a lipid keratopathy and posterior synechiae, which still prevent seeing the FO.