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36 year old man with redness, discharge and blurred vision in the left eye
Digital Journal of Ophthalmology 1997
Volume 3, Number 11
January 21, 1997
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Matthew Runde, M.D. | Wills Eye Hospital, Philadelphia, PA
Christopher Rapuano, M.D. | Wills Eye Hospital, Philadelphia, PA
Diagnosis and Discussion
Crack Cornea

This patient presented with a corneal ulcer which was found on culture testing to be sterile. In combination with diminished sensation of the corneas, the diagnosis was neurotrophic corneal ulceration. The patient repeatedly denied any surreptitious use of proparacaine or other topical commercial anesthetics. He did admit to frequent crack cocaine smoking up to the day of admission to the rehabilitation facility. This history in combination with the negative culture results on two separate occasions as well as a negative corneal biopsy effectively rule out infectious corneal ulceration. We believe this patient suffered FROM a neurotrophic keratopathy related to what has been termed crack keratopathy to describe a spectrum of corneal disease resulting directly FROM the toxic effect of crack cocaine on the cornea.

In their paper describing this syndrome, Sachs, Zagelbaum, and Hersh describe 14 patients with a spectrum of corneal diseases ranging FROM superficial punctate keratopathy (SPK) to epithelial defects to frank corneal ulceration resulting directly FROM crack smoking. In their study, 10 patients had corneal ulcers, and of 7 patients with unilateral ulcers, 6 had diffuse SPK in the other eye as did our patient. Nine of 13 ulcers were culture positive, and 7 of those grew either Staph or Strep. One culture grew Candida albicans, and another grew both H. Flu and Streptococci viridans. Five of 10 patients tested had decreased corneal sensitivity, as did our patient.

Sachs, Zagelbaum, and Hersh postulate five different mechanisms of damage FROM crack: a directly toxic effect of smoke, exposure due to decreased sensation, neurotrophic effects resulting FROM damage to corneal nerves, mild alkali burn, and mechanical trauma occurring after rubbing the irritated eyes.

Our patient fits the above description of crack keratopathy in that he is a young man without other known risk factors that predispose to corneal ulceration. We have since seen two other patients with similar histories of crack abuse presenting with keratopathy. This entity appears to be a fairly common cause of neurotrophic ulceration in young patients, and should be considered in the appropriate clinical setting.

Key Points:
- When a patient presents with a corneal ulcer that has the classic appearance of an oval, smooth edged, inferior paracentral infiltrate with an overlying epithelial defect with rolled edges, the diagnosis of neurotrophic keratopathy must be strongly suspected.
- An assessment of corneal sensation is crucial in the evaluation of a patient with an unusual corneal ulcer or when the pain is not proportional to the clinical findings.
- Since a sterile corneal ulcer is a diagnosis of exclusion, it is incumbent upon the ophthalmologist to prove this by vigorous culture and even biopsy if necessary.
- A conjunctival swab has little diagnostic utility in the management of a patient with a corneal ulcer.
- A corneal ulcer arising in a young patient who is not a contact lens wearer and who has had no trauma is distinctly unusual and should prompt one to consider crack keratopathy in the differential diagnosis.