The giant fornix syndrome: an unrecognized cause of chronic, relapsing, grossly purulent conjunctivitis.

AIM: To describe a group of elderly patients presenting with chronic, relapsing, copiously purulent conjunctivitis, in which the condition was often perpetuated by the sequestration of a large number of bacteria on a protein coagulum lodged in the recesses of a large upper conjunctival fornix.

PATIENTS AND

METHODS

Retrospective review of a noncomparative case series, drawn from patients attending the lacrimal clinic at Moorfields Eye Hospital.

OUTCOME MEASURES: Characterization of this unrecognized syndrome and its response to treatment.

RESULTS

Twelve patients (10 female) presented between the ages of 77 and 93 years (mean, 85; median, 86) with a history of chronic relapsing bacterial conjunctivitis affecting, with 2 exceptions, just one eye. All had experienced multiple episodes of markedly purulent conjunctivitis and chronic ocular discharge for between 8 and 48 months (mean, 23.5; median, 24) before referral, and the patients had received multiple courses of treatment. Three had successful external dacryocystorhinostomy (for nasolacrimal duct occlusion) before the final diagnosis of giant fornix syndrome was made, 9 had developed corneal vascularization and scarring before referral, and 5 had suffered prior spontaneous corneal perforation or thinning. All patients had deep upper conjunctival fornices in association with the changes of age-related dehiscence of the levator muscle aponeurosis. Copious amounts of thick, purulent debris and a yellow coagulum were lodged in the depths of the upper fornix-this debris universally culturing Staphylococcus aureus. The condition settled rapidly on appropriate systemic antibiotics (ciprofloxacin or ofloxacin), intensive topical antibiotics, and high-dose, high-potency steroids; some patients required repeated treatment or needed to continue the use of a single drop of a combined steroid-antibiotic to prevent relapse.

CONCLUSION

The capacious upper fornix of the elderly may harbor a coagulum colonized by S. aureus, leading to chronic conjunctivitis that may lead to severe sight impairment due to toxic keratopathy and secondary corneal vascularization.