Clinical & Experimental Ophthalmology | 2019
Infective conjunctivitis progressing to posterior scleritis
Abstract
Adenoviral and bacterial ocular adnexal infections are an extremely common ophthalmic presentation and usually self-limiting with innocuous clinical findings. This case demonstrates a previously undocumented complication of severe adenoviral conjunctivitis complicated by posterior scleritis. A 57-year-old man presented with a 3-day history of worsening right eyelid swelling with associated eye irritation, redness and blurred vision. He had a background of bilateral laser-assisted in situ keratomileusis (LASIK) 15 years prior and his medical history included hypertension, hypercholesterolaemia and an acute myocardial infarct, requiring a cardiac stent. On presentation, his visual acuity was six out of 12 in the right eye and six out of 7.5-2 in the left eye, with normal intraocular pressures of 16 and 13 mmHg, respectively. He had significant swelling and erythema of the right superior and inferior eyelids, conjunctival erythema, chemosis, mucopurulent discharge and punctate erosions at the edge of his LASIK scar. The patient had full ocular movements, however he reported pain with right gaze. There was no anterior chamber activity and a normal fundus on dilated exam. The left eye was unaffected. A conjunctival swab was collected from the right conjunctiva and routine bloods were normal, other than a mildly raised C reactive protein (16 mg/L). A computed tomography (CT) scan of the orbits demonstrated enhancement and thickening of the right preseptal soft tissue in keeping with preseptal cellulitis, with no orbital extension. The patient s ocular pain increased over the following 48 hours, raising the concern of progression to orbital cellulitis and he was treated with 4 days of intravenous (IV) ceftriaxone and topical chloramphenicol. Despite the gradual improvement in the right eyelid swelling, his left eye developed similar symptoms and the vision in the right eye deteriorated to six out of 24-1 (correcting to 6/21 with pinhole) and the left eye remained stable at six out of 7.5-2 and the patient complained of worsening ocular pain. On day five, he developed conjunctival pseudomembranes, corneal haze and oedema, anterior chamber activity (occasional cells) with keratic precipitates and a large subretinal swelling involving the macula and superior arcades in the right eye (see Figure 1). A B-scan was performed to further investigate the subretinal swelling and boggy thickening of the sclera was confirmed consistent with a diagnosis of posterior scleritis. His conjunctival PCR returned positive for adenovirus. A systemic work up for autoimmune conditions and systemic infective aetiologies was performed and was