Pembrolizumab‐associated ocular myasthenia gravis

Abstract

improvement in the right preseptal cellulitis and no evidence of postseptal extension. His pain and symptoms gradually improved on oral Naprosyn and prednisolone sodium phosphate 0.5% eye drops four times a day. At 1 month review the patient s symptoms and the subretinal swelling had resolved and his VA had improved to six out of 12-2 (NIPH) in the right eye and remained six out of 7.5 on pinhole in the left. Scleritis only rarely results from an infectious viral aetiology and typically has a preceding inciting factor such as ocular surgery or trauma. Causes of infectious scleritis described in the literature include herpes viruses, fungal infection (nocardia), parasites and bacteria including Pseudomonas aeruginosa, tuberculosis, leprosy, syphilis and Lyme disease. Adenovirus, a common cause of conjunctivitis can result in mild eyelid swelling, which has been reported in children to be confused with preseptal cellulitis, but is not a recognized cause of scleritis or preseptal cellulitis. The inflammation from this patient s adenoviral conjunctivitis appears to be the inciting factor for his ocular inflammation and development of posterior scleritis. Ophthalmologists reviewing patients with severe conjunctivitis, eyelid swelling, reduced visual acuity and pain with eye movements should be careful to look for signs of posterior scleritis in addition to orbital cellulitis. Even a reduction in visual acuity alone with symptoms of conjunctivitis warrants a dilated fundus exam and closer follow-up. This is reinforced by a case in the literature of bilateral posterior scleritis in a child misdiagnosed initially as viral conjunctivitis. The treatment of orbital cellulitis with IV antibiotics differs completely from the treatment of posterior scleritis, which typically requires oral corticosteroids or systemic immunosuppression. Both posterior scleritis and orbital cellulitis cause severe pain and may be sight threatening. This case demonstrates that viral conjunctivitis is not always a benign condition limited to the anterior eye but may result in more severe complications due to inflammation in neighbouring tissue.