Successful Treatment with Chronic Conjunctivitis: Removal of Tarsoconjunctival Crypt

Dear Editor, Contrary to the majority of acute conjunctivitis cases, chronic conjunctivitis can be caused by infection or inf lammation of the lacrimal duct system, conjunctival intraepithelial neoplasm, floppy eyelid syndrome, and immunologic reaction [1,2]. Symptoms are presented as insidious discharge, eye redness, and foreign body sensation. Chronic conjunctivitis is usually not self-limited. Some cases of antibiotic-resistant chronic conjunctivitis in conjunction with tarsoconjunctival crypts have been reported [3]. A thorough marsupialization of the crypts and short-term treatment with antibiotic eye drops can prevent recurrence. In this article, we report a patient with a similar form of chronic conjunctivitis that was refractory to multiple courses of antibiotic therapy. A 40-year-old female patient was referred to Ilsan Paik hospital for ocular discomfort and conjunctival injection on the left eye. The patient had been experiencing discharge and conjunctival injection for 1 month. Her vision was 20 / 20 in both eyes. A slit lamp biomicroscopy revealed scarring in the left upper and lower tarsoconjunctival, multiple concretions, and subconjunctival fibrosis (Fig. 1A). Topical therapies including gatif loxacin ophthalmic solution 0.3% and prednisolone acetate 1% were attempted but failed to resolve her symptoms. Culture of the discharge revealed Pseudomonas aeruginosa. We prescribed additional therapies of moxifloxacin, tobramycin ophthalmic solution, and oral doxycycline. Exposed concretions were removed twice, but her symptoms were not resolved. Two weeks after the original admission, right ocular discomfort was noted. We prescribed the same eye drops for her right eye as for the left eye. After 1 month of treatment and no change in symptoms, we decided to remove the tarsoconjunctival fibrosis of both eyes. The anatomic findings were similar in both upper eyelids (Fig. 1A and 1B). To determine the full extent of the conjunctival tunnels on the epitarsal surface, a probe was passed through the fistulous opening (Fig. 1C). The patient underwent marsupialization of both upper eyelid tarsoconjunctival crypts (Fig. 1D). Many concretions under subconjunctival fibrosis were removed. Bacterial culture of squeezed concretions was conducted, and the results were the same as the earlier culture obtained from the discharge: Pseudomonas aeruginosa. After marsupialization of both upper eyelid tarsoconjunctival crypts, conjunctival injection had much improved, and the dense conjunctival fibrosis was decreased but still apparent (Fig. 1E and 1F). Her discomfort gradually resolved. One month after the procedure, although the conjunctival fibrosis remained, we discontinued her eye drop treatment and medication because her symptoms of foreign body sensation, erythema, and discharge had improved. Here, we reported a patient suffering from continuous eye discomfort refractory to oral antibiotics and antibiotic eye drops. Tse et al. [3] have reported three cases of chronic mucopurulent conjunctival discharge that were refractory to multiple courses of antibiotic therapy. In all the cases of the study, the subjects’ symptoms were attributed to tarsoconjunctiva filled with coagulum and that was connected through fine fistula tracts. Based on these findings, Tse Korean J Ophthalmol 2016;30(4):311-312 http://dx.doi.org/10.3341/kjo.2016.30.4.311