The Daily Differential — Sunday, June 21, 2026

Keratitis and Corneal Ulcers

Keratitis and corneal ulcers can scar the visual axis, perforate the cornea, and blind a patient if treatment is delayed. Contact lens–associated infections are common, aggressive, and easy to under-triage.

By the Blue Fish Med Desk Jun 21, 2026 · Phoenix

A 29-year-old contact lens wearer sits under the triage fluorescent lights, one eye half-closed, tearing so hard the cheek is wet. He says the pain started as “grit” after an overnight shift, but now even the dim hallway light feels like a spotlight. The sclera is red, the eyelid keeps fluttering, and he can barely keep the lens story straight because he forgot to take them out. The eye looks angry in a way that makes you stop scrolling and lean in.

— What’s your move? Read on.

Before you read

Which finding separates simple abrasion from ulcerative infection?
What is the one mistake that risks permanent vision loss?

When to Think of It

Think of this when there is painful red eye + photophobia + foreign body sensation + decreased vision or a corneal opacity/infiltrate on exam. Contact lens use, trauma with vegetative matter, topical steroid use, or immunocompromise should push this to the top of the list.

Sick or Not Sick

The fork is simple epithelial defect vs. sight-threatening corneal infection/perforation risk. Any decreased vision, corneal infiltrate/opacity, hypopyon, central ulcer, contact lens wear, or severe pain/photophobia is “treat as ulcerative keratitis until proven otherwise.”

The First Fifteen Minutes

Topical anesthetic for exam only if needed: tetracaine 0.5% 1–2 drops in the ED to permit fluorescein/slit-lamp exam, because you need a real corneal look; do not prescribe for home use.
Pain control: ibuprofen 400–600 mg PO or acetaminophen 650–1,000 mg PO/IV if needed, because it improves comfort without obscuring exam findings.
Cycloplegic if significant ciliary spasm/photophobia: cyclopentolate 1% 1 drop or homatropine 2% 1 drop in the affected eye, because it relieves painful spasm and photophobia.
Suspected bacterial keratitis/corneal ulcer, especially contact lens wearer → start topical fluoroquinolone: moxifloxacin 0.5% 1 drop q1h while awake or ciprofloxacin 0.3% 1–2 drops q1h initially, because high local antibiotic levels are needed to suppress corneal pathogens.
If severe ulcer, central lesion, or ophthalmology directs fortified therapy: fortified tobramycin 14 mg/mL and cefazolin 50 mg/mL or vancomycin-based drops per ophthalmology protocol; dosing varies meaningfully, so check local/ophthalmology guidance.
If concern for herpetic keratitis (dendrites, reduced corneal sensation) → do not start topical steroids; urgent ophthalmology, because steroids can worsen HSV corneal disease.
Remove contact lenses immediately and bring the case/lens/case if available, because it reduces ongoing inoculation and helps identify pathogens.

Definitive Care & Disposition

Urgent ophthalmology consultation is required for any ulcer/infiltrate, visual change, hypopyon, central or large lesion, corneal thinning, immunocompromise, or inability to ensure follow-up. Small peripheral abrasions can sometimes be outpatient, but true corneal ulcer/keratitis generally gets same-day ophthalmology and often admission if severe, bilateral, atypical, or fungal/amoebic disease is suspected. Continue topical antibiotics as directed; later therapy may include culture-directed treatment, antifungals (e.g., natamycin for fungal keratitis), or anti-amoebic regimens.

How This One Kills

The fatal error is treating an infectious corneal ulcer like a routine abrasion and sending the patient away with no urgent follow-up—this can progress to corneal melt, perforation, endophthalmitis, and permanent vision loss.

The Differential — What Else Looks Like This

Corneal abrasion — epithelial defect without stromal infiltrate/opacity; confusing it for ulcer delays antibiotics and ophthalmology.
Acute glaucoma — severe pain, halos, mid-dilated fixed pupil, high IOP; confusing it for keratitis delays pressure-lowering therapy and threatens the optic nerve.
Anterior uveitis/iritis — consensual photophobia and ciliary flush with a quiet cornea; missing it can lead to synechiae and chronic vision loss.
Endophthalmitis — profound vision loss, hypopyon, post-op/injection history; missing it is catastrophic because it needs immediate intraocular therapy.

The Second-Day Story

Older adults, diabetics, and steroid-treated patients may have less dramatic pain but worse disease, and contact lens users may present late with just “irritation” and blurry vision. Any unilateral red eye with decreased visual acuity deserves fluorescein staining and slit-lamp inspection; if you see a focal infiltrate or corneal haze, assume infection until an eye specialist says otherwise.

Back to Our Patient

Back to our patient: the 29-year-old contact lens wearer with tearing, photophobia, and blurry unilateral pain gets a slit-lamp exam showing a corneal infiltrate with fluorescein uptake, so this is infectious keratitis/corneal ulcer, not a simple abrasion. Because contact lens use and decreased vision make him high risk, he goes straight into the First Fifteen with topical fluoroquinolone drops, no contact lens use, and pain control after exam, then same-day ophthalmology for culture consideration and close follow-up, with admission if the lesion is central or severe.

Patient Presentation to Attending

How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling

“29-year-old man with contact lens use presents with one day of severe left eye pain, tearing, photophobia, and blurred vision. He says it started like a scratch after a night shift, but it has worsened and he can barely tolerate light; no trauma with metal, no chemical exposure, and no headache or neurologic symptoms. On exam he has conjunctival injection, obvious discomfort, and decreased visual acuity in the affected eye; fluorescein shows a focal corneal epithelial defect with surrounding infiltrate, and I don’t see a mid-dilated fixed pupil or elevated IOP features to suggest acute glaucoma. This is most concerning for infectious keratitis/corneal ulcer, likely bacterial given the contact lens history. I’ve removed the lens, started topical fluoroquinolone drops, given analgesia, and I’m calling ophthalmology now for urgent evaluation and disposition.”

Study Directive

Draw the red painful eye algorithm from memory: abrasion vs keratitis vs glaucoma vs uveitis.
Practice naming the bedside discriminators: visual acuity change, fluorescein uptake pattern, corneal opacity, pupil shape, and IOP clues.
Write out the first-hour orders for a contact lens wearer with suspected ulcer: exam, lens removal, topical fluoroquinolone, analgesia, ophthalmology call.
Review when steroids are harmful in eye disease, especially HSV keratitis and microbial ulcers.

Recent Literature

Review or guideline Infectious keratitis: A review
Cabrera-Aguas M, Khoo P, Watson SL · Clin Exp Ophthalmol, 2022 · PMID 35610943 · cited 344×

A broad clinical review of infectious keratitis that reinforces the ED priorities: suspect it in painful red eyes with corneal staining or contact lens use, start prompt topical antimicrobial therapy when indicated, and arrange urgent ophth

Full text · open access

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Post-Tonsillectomy Hemorrhage

Post-tonsillectomy hemorrhage is a true airway and hemorrhagic emergency; swallowed blood can hide severity, and even minor-appearing bleeding can herald...

The Case

A 12-year-old boy is sitting bolt upright in the chair, pale and quiet, with a red stain spreading through the tissues in his fist. His mother says he woke up tasting blood and then started spitting “just a little” into the sink, but now the saliva is pink and his throat keeps making him swallow. He won’t lie flat, keeps pointing to his mouth, and there’s a raw metallic smell in the room. No one has seen him vomit, but the sink has a dark clotted ring and he looks more drained than he wants to admit.

Before You Read

What is the first priority when the post-tonsillectomy patient is bleeding?
Which bleeding pattern is dangerous even if the amount looks small?
What bedside move can worsen the hemorrhage?

Why It Matters

Post-tonsillectomy hemorrhage is a true airway and hemorrhagic emergency; swallowed blood can hide severity, and even minor-appearing bleeding can herald major vessel exposure. Children can deteriorate quickly from aspiration, shock, or obstruction.

When to Think of It

Think of this diagnosis with any oral bleeding, frequent swallowing, hematemesis, hemoptysis-like spitting, or clot in the tonsillar fossa after tonsillectomy. It is classically within 24 hours (primary) or 5–10 days (secondary) after surgery.

Sick or Not Sick

The key fork is active bleeding / clot present / unstable vs. no active bleeding and fully stopped. Any ongoing hemorrhage, repeated swallowing, tachycardia, pallor, or difficulty managing secretions is high risk and needs immediate ENT involvement.

The First Fifteen Minutes

Suction the oropharynx gently and have the patient spit blood into a basin if able, because swallowed blood obscures severity and increases aspiration risk.
Position upright, leaning forward, because this reduces aspiration and helps visualize the source.
Two large-bore IVs and monitor vitals; if unstable, begin resuscitation with balanced crystalloid 20 mL/kg IV and blood products as needed, because children can hide shock until late.
ENT emergently for any active bleed or clot.
Ice water gargle or swish/spit may be used in a cooperative, stable patient while awaiting ENT, because cold vasoconstriction can temporize minor bleeding.
If active bleeding is present and the child can cooperate, topical vasoconstrictor/pressure measures may be used by ENT; ED should not aggressively manipulate the tonsillar fossa unless directed.
Antiemetic if needed: ondansetron 0.15 mg/kg IV/PO (max 8 mg) for vomiting/retching, because retching can worsen bleeding and aspiration risk.
If severe bleeding with shock or airway compromise, prepare for airway management and massive transfusion; intubation is difficult and should involve the most experienced operator available.

Definitive Care & Disposition

All patients with true post-tonsillectomy bleeding need ENT evaluation and usually observation or admission. Active bleeds, recurrent bleeds, significant anemia, or unstable patients require operative control and inpatient monitoring; even if bleeding stops, many need prolonged observation because rebleeding can occur.

How This One Kills

The classic failure is dismissing “just a little blood” while the child is repeatedly swallowing it—this can mask ongoing hemorrhage until the patient suddenly aspirates or decompensates.

The Atypical Presentation

Some children do not vomit blood at all; they simply swallow, become pale, or refuse to talk because talking hurts. Teenagers and adults may be more articulate but still underestimate the amount because blood is diluted in saliva; any persistent swallowing, throat clearing, or taste of blood after tonsillectomy should be treated as hemorrhage until proven otherwise.

Back to Our Patient

Back to our patient: the 12-year-old boy with persistent swallowing, blood-streaked saliva, and a clot in the tonsillar fossa has post-tonsillectomy hemorrhage until proven otherwise. He stays upright, gets suction and IV access, and because even “small” bleeding can be significant, ENT is called immediately for bedside and likely operative control; if he is tachycardic, pale, or actively bleeding, he gets resuscitation and admission after hemostasis, with airway planning kept front and center.

Patient Presentation to Attending

“12-year-old boy status post tonsillectomy with concern for postoperative bleeding. His mother reports recurrent swallowing and blood-tinged saliva, and on exam he is pale, spitting blood, and has a clot in the tonsillar fossa; I’m concerned this is active post-tonsillectomy hemorrhage rather than routine postoperative irritation. I’ve kept him upright, avoided aggressive manipulation, placed IV access, and am calling ENT emergently. Depending on his ongoing bleeding and vitals, he may need resuscitation, operative hemostasis, and admission for observation.”

Study Directive

Rehearse the first-five-minute tonsillectomy bleed algorithm from memory.
Memorize primary vs secondary timing and what each implies about risk.
Practice a focused oral presentation that includes airway, hemodynamics, and ENT disposition.
Review pediatric resuscitation fluid dosing and the threshold for blood product escalation.

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Mechanism Pearl of the Day: Several of today’s problems hinge on a hidden lumen becoming dangerous because you can’t see the damage from the outside: corneal infection beneath a red eye, optic nerve inflammation behind a normal-appearing globe, a trach tube failing inside a “secure” airway, and tonsillar bleeding masked by swallowed blood. In each, bedside discrimination beats reassurance.

Key Medications

Ondansetron 0.15 mg/kg IV/PO (max 8 mg) for vomiting/retching.
0.9% normal saline or balanced crystalloid 20 mL/kg IV bolus for resuscitation if unstable.
Acetaminophen dosing is weight-based in children; use institutional pediatric dosing.
Specific hemostatic/topical measures are usually ENT-directed and vary by institution.

High-Yield Pearls

Swallowing blood is the clue — many children don’t spit it out.
A tonsillar clot is not reassuring; it can be the tamponading edge of active hemorrhage.
Post-tonsillectomy bleeding is an airway problem before it is a “bleeding history” problem.

The Mimics

Epistaxis with swallowed blood — nasal source and posterior drainage; confusing it misses a surgical throat source.
Postoperative nausea/vomiting — can be from swallowed blood, but if you treat it as simple vomiting you miss hemorrhage.
Peritonsillar abscess — muffled voice and sore throat without postoperative timing; confusing it misses bleeding control.
Upper GI bleeding — hematemesis history, abdominal symptoms; confusing it diverts attention from the oropharynx.

Board Question

A 9-year-old is 7 days post-tonsillectomy and presents with repeated swallowing, blood in the saliva, and a visible clot in the tonsillar fossa. What is the most appropriate next step?

AReassure and discharge if the bleeding is not brisk
BPlace the child supine for inspection and send labs only
CKeep upright, obtain IV access, and urgently consult ENT
DGive oral antibiotics and outpatient follow-up tomorrow

Reveal answer

Correct: C

A clot or recurrent swallowing after tonsillectomy is a bleed until proven otherwise and can worsen quickly. The correct move is immediate stabilization, upright positioning, IV access, and urgent ENT involvement; waiting for brisk bleeding is too late.

Recent Literature

Review or guideline Horrific Hemorrhage: Post Tonsillectomy Bleeding Management
Emerg Med Clin North Am, 2025 · cited 1×

EM-focused review of post-tonsillectomy bleeding priorities: early ENT/anesthesia involvement, airway readiness, suction/positioning, IV access/resuscitation, and temporizing hemostatic measures such as topical or nebulized tranexamic acid.
Recent clinical Post-tonsillectomy hemorrhage following ketorolac in children: A 2010-2024 national database analysis
Int J Pediatr Otorhinolaryngol, 2026

Large pediatric database study relevant to analgesic choices after tonsillectomy, helping frame whether ketorolac exposure is associated with subsequent hemorrhage risk.

TheDaily Differential

Keratitis and Corneal Ulcers

When to Think of It

Sick or Not Sick

The First Fifteen Minutes

Definitive Care & Disposition

How This One Kills

The Second-Day Story

Study Directive

Recent Literature

More in Today's Issue

Optic Neuritis

Complications of Tracheostomies

Post-Tonsillectomy Hemorrhage

Yesterday’s Differential

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