Painless Geographic Corneal Ulcer In An Elderly Patient: A Diagnostic Pitfall In Neurotrophic Keratitis

To report a case of neurotrophic keratitis presenting as a painless geographic corneal ulcer and to highlight the importance of corneal sensitivity assessment in differentiating it from infectious keratitis.

Tertiary ophthalmology referral center, Tirana, Albania

An 71-year-old woman presented with decreased visual acuity and mild ocular discomfort in her right eye. She was referred from a primary ophthalmology setting due to persistent epithelial defect. 

Single observational case report.

Notably, the patient reported minimal pain despite significant corneal findings. Slit-lamp examination revealed conjunctival hyperemia and a central corneal ulcer associated with a temporal geographic epithelial defect and loose surrounding epithelium. Fluorescein staining confirmed a large epithelial defect extending temporally. 

Corneal sensitivity was markedly reduced compared to the fellow eye. 

The clinical findings were consistent with Stage 2 neurotrophic keratitis, likely secondary to previous herpetic disease. The patient was treated with oral acyclovir, topical tobramycin/dexamethasone, and cycloplegic therapy. The patient was also advised to maintain eyelid closure to promote epithelial healing. 

At two-week follow-up, slit-lamp examination demonstrated partial re-epithelialization with a reduction in the size of the epithelial defect.

Large painless geographic epithelial defects in elderly patients represent a diagnostic pitfall. Routine corneal sensitivity assessment is critical for distinguishing neurotrophic keratitis from infectious keratitis and for preventing vision-threatening complications.