A 50-years-old male patient presented to the emergency room complaining of itching, red-eye, and tearing of both eyes. His past medical history was positive for asthma. Past ophthalmologic history was unremarkable. Visual acuity was 20/20 in both eyes. Anterior segment biomicroscopy revealed bilateral mild hyperemia and follicular reaction in the inferior conjunctival fornix. At his first visit, he presented conjunctival pseudomembrane in his right eye, and the diagnosis of a presumable viral conjunctivitis was assumed based on clinical findings. We prescribed preservative-free lubricant eye drops and advised the patient about the contagious risk associated.
Patient returned 1 week later complaining of worsening symptoms in his right eye. He presented with painful swelling of the superior and inferior eyelids, yellowish mucopurulent discharge, and decrease of vision in this eye. Visual acuity decreased to hand motion in the right eye and remained 20/20 in the left eye. The slit-lamp exam was impaired in the right eye due to the lids swallow. We noticed mucopurulent discharge, diffuse hyperemia with conjunctival necrosis, and a dense yellowish membrane covering the anterior surface (Fig. 1a). Visualization of the cornea and the anterior segment were compromised. The left eye showed a mild follicular reaction, but cornea, lens, and the anterior chamber were normal.
Conjunctival scraps of the mucopurulent discharge and the conjunctival lesions were performed. Bacterioscopy showed gram-positive cocos. Microbiology revealed Streptococcus pyogenes growth which was responsive to most of the antibiotics tested.
We performed a debridement of the necrotic conjunctival tissue. During the procedure, we noticed that there was a conjunctival ulcer with necrotic tissue affecting the Tenon's capsule, but preserving the sclera (Fig. 1b). Conjunctival and Tenon biopsy showed an exudative chronic conjunctivitis. Orbital computerized tomography images were suspicious of post-septal involvement. The patient was hospitalized and medicated with systemic antibiotics (ceftriaxone and clindamycin). Topical 0.5% moxifloxacin and 1% prednisolone acetate eye drops were prescribed right after systemic treatment was initiated.
Due to the possibility of an autoimmune disease as a differential diagnosis, we performed a rheumatologic workup, but all ancillary exams related were negative. Patient was also tested for infectious diseases including HIV, syphilis, cytomegalovirus, tuberculosis, and hepatitis, but all tests were negative.
Patient-reported significant improvement of his symptoms 4-5 days after antibiotic therapy was initiated. The visual acuity improved to 20/20 in the right eye. There was a mild conjunctival hyperemia with remarkable improvement of the ulceration (Fig. 1c). Clinical and functional recover was achieved after 2 weeks of treatment. Topical preservative-free artificial tears were maintained for 2 months.