Initial Management: Ophthalmic Examination
The initial step is an urgent ophthalmic examination before initiating any treatment, as pain, photophobia, and blurred vision are red flags indicating potential vision-threatening conditions that require specialist assessment to differentiate between bacterial keratitis, viral keratoconjunctivitis, herpes simplex keratitis, or anterior uveitis. 1
Why Examination Must Come First
- Pain combined with photophobia indicates corneal involvement, which can represent bacterial keratitis, viral keratoconjunctivitis, or herpes simplex keratitis—all requiring specialist assessment before treatment 1
- Blurred vision is a red flag mandating urgent ophthalmology referral, as it suggests more than superficial inflammation and may indicate corneal infiltration, anterior chamber involvement, or other vision-threatening pathology 1
- The American Academy of Ophthalmology states that decreased vision, severe pain, and photophobia are warning signs demanding immediate ophthalmological consultation before treatment initiation 1
Critical Diagnostic Considerations
The examination must differentiate between several serious conditions:
- Viral keratoconjunctivitis presents with watery discharge, photosensitivity, and pain, requiring slit-lamp examination to identify corneal epithelial defects, subepithelial infiltrates, or pseudomembranes 1
- Bacterial keratitis features suppurative stromal infiltrates with indistinct edges, epithelial defects, and anterior chamber reaction—pain, photophobia, and blurred vision are cardinal symptoms requiring immediate evaluation 1
- Herpes simplex keratitis presents with unilateral red eye, watery discharge, pain, and photophobia, and can cause devastating complications including stromal keratitis, corneal scarring, perforation, and vision loss 1, 2
Required Examination Components
Urgent ophthalmologic examination must include visual acuity measurement, external examination, slit-lamp biomicroscopy, and determination of the need for cultures and smears 1
The initial evaluation should assess: 2
- Visual acuity measurement to document baseline function
- External examination for regional lymphadenopathy, skin abnormalities, eyelid abnormalities, and conjunctival reaction patterns
- Slit-lamp biomicroscopy to evaluate corneal integrity, anterior chamber, and identify specific pathology
Why Starting Treatment First Is Dangerous
- Starting topical antibiotics or corticosteroids before proper examination can worsen herpetic infections and mask accurate diagnosis and severity grading, delaying appropriate management 1
- Never start corticosteroids before proper examination, as they can worsen infectious keratitis from Acanthamoeba, Nocardia, fungus, or HSV 1
- Do not assume "conjunctivitis" when pain and photophobia are prominent—these symptoms indicate deeper ocular structure involvement 1
Clinical Reasoning
While watery discharge might suggest viral or allergic conjunctivitis in isolation 3, the presence of pain, photophobia, and blurred vision in this patient elevates the clinical concern significantly 1. These symptoms indicate potential corneal or intraocular involvement that requires definitive diagnosis before any therapeutic intervention 2, 4.
Answer: D) Ophthalmic examination