Should a patient with a history of bell palsy and recent keratitis diagnosis be referred to an ENT specialist before or after seeing an eye doctor?

Management of Bell's Palsy with Keratitis

A patient with Bell's palsy who has developed keratitis should be referred to an ophthalmologist immediately before seeing an ENT specialist, as keratitis represents an urgent ocular complication that can lead to permanent vision loss if not promptly treated.

Rationale for Ophthalmology Referral First

Bell's palsy with keratitis represents a serious ocular complication requiring immediate attention. According to the American Academy of Ophthalmology's Bacterial Keratitis Preferred Practice Pattern:

1. Keratitis can cause substantial visual loss, even if the infecting organism is successfully eradicated, especially when involving the central or paracentral cornea 1
2. Corneal scarring from keratitis can lead to permanent vision impairment 1
3. Lagophthalmos (inability to close the eyelid) from Bell's palsy increases the risk of exposure keratitis, corneal ulceration, and potentially vision loss 2

Management Algorithm

Step 1: Immediate Ophthalmology Referral

• Keratitis requires urgent evaluation by an ophthalmologist to:
  • Determine the type and severity of keratitis
  • Initiate appropriate antibiotic therapy
  • Prevent corneal scarring and vision loss
  • Address the exposure issues from lagophthalmos

Step 2: Ophthalmological Treatment

• Treatment will likely include:
  • Topical antibiotics (fluoroquinolones are first-line for bacterial keratitis) 3
  • Possible corneal cultures for severe cases 1
  • Management of exposure issues related to Bell's palsy
  • Lubricants and possibly taping the eyelid closed at night

Step 3: ENT Referral

• After initial ophthalmological management, ENT referral is appropriate for:
  • Evaluation and management of the underlying Bell's palsy
  • Consideration of oral corticosteroids (prednisone 50-60mg daily for 5 days with 5-day taper) 4
  • Possible antiviral therapy (valacyclovir 1g three times daily for 7 days) 4

Important Considerations

Ocular Protection in Bell's Palsy

• Lagophthalmos from Bell's palsy requires aggressive ocular surface protection 2
• Options include:
  • Artificial tears during the day
  • Lubricating ointment at night
  • Moisture chambers or taping eyelids closed
  • Possible temporary or permanent surgical interventions for persistent cases

Timing Considerations

• Keratitis represents an urgent condition requiring same-day evaluation
• Delay in treatment can lead to corneal scarring and permanent vision loss 1
• Bell's palsy management is important but less time-sensitive than keratitis management

Follow-up Care

• Regular ophthalmology follow-up is necessary until:
  • Keratitis resolves
  • Adequate ocular protection is established
  • Risk of exposure complications is minimized

Caution and Pitfalls

• Do not delay ophthalmological evaluation for keratitis while waiting for ENT consultation
• Avoid patching the eye in infectious keratitis as it may worsen the infection 3
• Surgical decompression for Bell's palsy is not recommended unless a tumor is suspected 5
• Be aware that herpes simplex virus can cause both keratitis and Bell's palsy, which may require specific antiviral treatment 6, 7

The priority in this case must be protecting the patient's vision by addressing the keratitis first, followed by appropriate management of the underlying Bell's palsy.