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Epidemic Keratoconjunctivitis Associated With Blepharoptosis
360
September, 1988
AMERICAN JOURNAL OF OPHTHALMOLOGY
Epidemic Keratoconjunctivitis Associated With Blepharoptosis Scott Corin, M . D . , and John Harvey, M . D . Oculoplastic, Reconstructive Lacrimal, and Orbital Service, Division of Ophthalmology, Department of Surgery, McMaster University Medical Center. Inquiries to John Harvey, M.D,, Room 4V2, McMaster University Medical Center, Department of Surgery, 1200 Main St., Hamilton, Ontario, Canada LN8 3Z5. Epidemic keratoconjunctivitis is an adenoviral infection of the cornea and conjunctiva. Complications of this disease include subepithelial infiltrates, iritis, and conjunctival pseudomembranes. 1 3 An outbreak of more than 200 cases of epidemic keratoconjunctivitis occurred in the Hamilton, Ontario, area in the fall of 1986. Two patients were referred to our Oculo plastic Service for evaluation of blepharoptosis developing after epidemic keratoconjunctivitis. Case 1 An 18-year-old woman developed epidemic keratoconjunctivitis in October 1986. She had bilateral eyelid swelling, with the left eyelid more severely affected than the right. She was referred for evaluation of an acquired left upper eyelid blepharoptosis. Family photo graphs showed no evidence of blepharoptosis
^w^ Fig. 1 (Corin and Harvey). Case 1. An 18-year-old woman with 1 mm of left upper eyelid blepharopto sis after epidemic keratoconjunctivitis infection.
Fig. 3 (Corin and Harvey). Case 2. A 77-year-old woman with 2 mm of right upper eyelid blepharopto sis after epidemic keratoconjunctivitis infection. before the infection. On examination, palpebral fissures were 11 mm on the right and 10 mm on the left. Levator function was 15 mm on each side. The eyelid crease was noted to be higher on the left upper eyelid than on the right (Fig. 1). She underwent a successful FasanellaServat blepharoptosis repair in August 1987 (Fig- 2). Case 2 A 77-year-old woman developed epidemic keratoconjunctivitis in December 1986. She had a severe case with subepithelial infiltrates bilat erally and swelling of all four eyelids. After the infection, she noted that her upper eyelids were droopy, with the right eyelid lower than the left. On examination, her palpebral fissures were 7 mm on the right and 9 mm on the left (Fig. 3). Levator function was 15 mm bilateral ly. Eyelid creases were noted to be high in each upper eyelid. She declined surgical correction. Epidemic keratoconjunctivitis is a highly contagious disease. The subepithelial infil trates that develop may decrease visual acuity. Pseudomembranes of the conjunctiva may occur in severe cases and may result in perma nent conjunctival scarring. Our two patients developed blepharoptosis after an adenoviral infection. On the basis of the clinical examina tion in two cases, and the operative findings in one case, we postulate that the mechanism of blepharoptosis is a levator attenuation/disinsertion. The marked eyelid edema associated with the viral infection may weaken the levator-tarsal attachment leading to blepharo ptosis and elevation of the eyelid crease.
References Fig. 2 (Corin and Harvey). Case 1. Two months after Fasanella-Servat for correction of left upper eyelid blepharoptosis.
1. Knopf, H. L. S., and Hierholzer, J. C : Clinical and immunologic responses in patients with viral
Vol. 106, No. 3
Letters to the Journal
keratoconjunctivitis. Am. J. Ophthalmol. 80:661, 1975. 2. Dawson, C. R., Hanna, L., Wood, T. R., and Despain, R. P.: Adenbvirus type 8 keratoconjunc tivitis in the United States. Epidemiologic, clinical, and microbiological features. Am. J. Ophthalmol. 69:473, 1970. 3. Grayson, M. (ed.): Diseases of the Cornea, ed. 2. St. Louis, C. V. Mosby Co., 1983. Chapter 6, Acute and chronic follicular conjunctivitis, pp. 114-128. Chapter 8, Viral diseases, pp. 150-198. Chapter 14, Immune and mucous membrane diseases, pp. 347440.
Ocular Infections Secondary to Pasteurella multocida Mary P. McNamara, M . D . , Michael Richie, M . D . , and Nigar Kirmani, M . D . Division of Infectious Diseases (M.P.M. and N.K.), and the Department of Ophthalmology (M.R.), Med ical College of Wisconsin.
361
temperature of 100.4 F with visual acuity of R.E.: 20/80+ and L.E.: counting fingers. Pinhole visual acuity of 20/70 in the right eye and 20/400 in the left eye was recorded. Intraocular pressures were R.E.: 22 mm Hg and L.E.: 35 mm Hg with a conspicuous afferent pupillary defect in the left. Extraocular movement was restricted in both lateral and downgaze on the left with 2 mm of proptosis present in the left eye. Results of external examination showed marked tense swelling of the left upper eyelid associated with copious green discharge and conjunctival hyperemia without chemosis. The cornea was clear and the anterior chamber was aphakic with no inflammation. A posterior chamber lens and capsulotomy were present. Ophthalmoscopy disclosed clear media with a cup to disk ratio of 0.8 in the right eye and 0.9 in the left eye. The remainder of the retina was normal. Enlarged, tender, left anterior cervical lymph nodes were also noted.
Laboratory studies showed a white blood cell count of 10,700/mm 3 with 78% neutrophils. Gram stain of the discharge from the left eye showed many neutrophils but no organisms. Computed tomography of the head demon Inquiries to Nigar Kirmani, M.D., Medical Service/lllN, strated a large soft tissue swelling in the face, Veterans Administration Medical Center, Milwaukee, WI extending from the malar eminence of the fron 53295. tal sinus on the left. The optic nerve and extraocular muscles appeared normal. No fluid col Pasteurella multocida is a gram-negative lection in the orbit was seen, and the sinuses coccobacillus found in the normal flora of cats were normal. and dogs. Human infection secondary to P. multocida usually involves contact with ani The patient was treated with timentin and mal secretions such as a bite or a lick. Pasteurel gentamicin intravenously and gentamicin topi la multocida has been implicated in a variety of cally. Pasteurella multocida was grown from both infections, including skin, bone and joint, pul a blood culture and drainage from the eye. monary, cardiovascular, and central nervous Intravenous antibiotics given for six days were system infections. 12 Ocular infections caused followed by amoxicillin orally for eight days. by P. multocida, however, are rare. A review The patient was able to open his left eye on the of the literature shows only nine cases third day of treatment. Follow-up examination of P. multocida ocular infections reported to showed complete resolution of the edema and date. We studied a case of orbital and perifull extraocular movements. Final visual acuity orbital cellulitis and conjunctivitis caused by remained R.E.: 20/70 and L.E.: 20/400. The P. multocida. afferent pupillary defect resolved. On further questioning, the patient admitted having a dog An 80-year-old man with a history of extraat home that frequently licked the patient's capsular cataract extraction with an intraocular hands and occasionally his face. lens implant in the left eye (four years previ ously), bilateral chronic open-angle glaucoma, Human infections from P. multocida usually and best-corrected visual acuity of R.E.: 20/70 result from direct inoculation through bites, and L.E.: 20/400 complained of pain and swell but can stem from contact with animal secre ing in the left eye of 24 hours' duration, associ tions. Ocular infections caused by P. multocida ated with copious amounts of green discharge. are extremely rare. Previously reported cases He denied any visual disturbance, but endinclude an 11-year-old girl who suffered a cat stage glaucoma in the affected eye made inter scratch to her eye and developed endophthalpretation difficult. No history of trauma to the mitis, 3 a 44-year-old woman who developed eye was noted. a corneal ulcer with hypopyon after her eye Results of physical examination disclosed a was bumped by her pet dog, 4 a 10-year-old boy
September, 1988
AMERICAN JOURNAL OF OPHTHALMOLOGY
Epidemic Keratoconjunctivitis Associated With Blepharoptosis Scott Corin, M . D . , and John Harvey, M . D . Oculoplastic, Reconstructive Lacrimal, and Orbital Service, Division of Ophthalmology, Department of Surgery, McMaster University Medical Center. Inquiries to John Harvey, M.D,, Room 4V2, McMaster University Medical Center, Department of Surgery, 1200 Main St., Hamilton, Ontario, Canada LN8 3Z5. Epidemic keratoconjunctivitis is an adenoviral infection of the cornea and conjunctiva. Complications of this disease include subepithelial infiltrates, iritis, and conjunctival pseudomembranes. 1 3 An outbreak of more than 200 cases of epidemic keratoconjunctivitis occurred in the Hamilton, Ontario, area in the fall of 1986. Two patients were referred to our Oculo plastic Service for evaluation of blepharoptosis developing after epidemic keratoconjunctivitis. Case 1 An 18-year-old woman developed epidemic keratoconjunctivitis in October 1986. She had bilateral eyelid swelling, with the left eyelid more severely affected than the right. She was referred for evaluation of an acquired left upper eyelid blepharoptosis. Family photo graphs showed no evidence of blepharoptosis
^w^ Fig. 1 (Corin and Harvey). Case 1. An 18-year-old woman with 1 mm of left upper eyelid blepharopto sis after epidemic keratoconjunctivitis infection.
Fig. 3 (Corin and Harvey). Case 2. A 77-year-old woman with 2 mm of right upper eyelid blepharopto sis after epidemic keratoconjunctivitis infection. before the infection. On examination, palpebral fissures were 11 mm on the right and 10 mm on the left. Levator function was 15 mm on each side. The eyelid crease was noted to be higher on the left upper eyelid than on the right (Fig. 1). She underwent a successful FasanellaServat blepharoptosis repair in August 1987 (Fig- 2). Case 2 A 77-year-old woman developed epidemic keratoconjunctivitis in December 1986. She had a severe case with subepithelial infiltrates bilat erally and swelling of all four eyelids. After the infection, she noted that her upper eyelids were droopy, with the right eyelid lower than the left. On examination, her palpebral fissures were 7 mm on the right and 9 mm on the left (Fig. 3). Levator function was 15 mm bilateral ly. Eyelid creases were noted to be high in each upper eyelid. She declined surgical correction. Epidemic keratoconjunctivitis is a highly contagious disease. The subepithelial infil trates that develop may decrease visual acuity. Pseudomembranes of the conjunctiva may occur in severe cases and may result in perma nent conjunctival scarring. Our two patients developed blepharoptosis after an adenoviral infection. On the basis of the clinical examina tion in two cases, and the operative findings in one case, we postulate that the mechanism of blepharoptosis is a levator attenuation/disinsertion. The marked eyelid edema associated with the viral infection may weaken the levator-tarsal attachment leading to blepharo ptosis and elevation of the eyelid crease.
References Fig. 2 (Corin and Harvey). Case 1. Two months after Fasanella-Servat for correction of left upper eyelid blepharoptosis.
1. Knopf, H. L. S., and Hierholzer, J. C : Clinical and immunologic responses in patients with viral
Vol. 106, No. 3
Letters to the Journal
keratoconjunctivitis. Am. J. Ophthalmol. 80:661, 1975. 2. Dawson, C. R., Hanna, L., Wood, T. R., and Despain, R. P.: Adenbvirus type 8 keratoconjunc tivitis in the United States. Epidemiologic, clinical, and microbiological features. Am. J. Ophthalmol. 69:473, 1970. 3. Grayson, M. (ed.): Diseases of the Cornea, ed. 2. St. Louis, C. V. Mosby Co., 1983. Chapter 6, Acute and chronic follicular conjunctivitis, pp. 114-128. Chapter 8, Viral diseases, pp. 150-198. Chapter 14, Immune and mucous membrane diseases, pp. 347440.
Ocular Infections Secondary to Pasteurella multocida Mary P. McNamara, M . D . , Michael Richie, M . D . , and Nigar Kirmani, M . D . Division of Infectious Diseases (M.P.M. and N.K.), and the Department of Ophthalmology (M.R.), Med ical College of Wisconsin.
361
temperature of 100.4 F with visual acuity of R.E.: 20/80+ and L.E.: counting fingers. Pinhole visual acuity of 20/70 in the right eye and 20/400 in the left eye was recorded. Intraocular pressures were R.E.: 22 mm Hg and L.E.: 35 mm Hg with a conspicuous afferent pupillary defect in the left. Extraocular movement was restricted in both lateral and downgaze on the left with 2 mm of proptosis present in the left eye. Results of external examination showed marked tense swelling of the left upper eyelid associated with copious green discharge and conjunctival hyperemia without chemosis. The cornea was clear and the anterior chamber was aphakic with no inflammation. A posterior chamber lens and capsulotomy were present. Ophthalmoscopy disclosed clear media with a cup to disk ratio of 0.8 in the right eye and 0.9 in the left eye. The remainder of the retina was normal. Enlarged, tender, left anterior cervical lymph nodes were also noted.
Laboratory studies showed a white blood cell count of 10,700/mm 3 with 78% neutrophils. Gram stain of the discharge from the left eye showed many neutrophils but no organisms. Computed tomography of the head demon Inquiries to Nigar Kirmani, M.D., Medical Service/lllN, strated a large soft tissue swelling in the face, Veterans Administration Medical Center, Milwaukee, WI extending from the malar eminence of the fron 53295. tal sinus on the left. The optic nerve and extraocular muscles appeared normal. No fluid col Pasteurella multocida is a gram-negative lection in the orbit was seen, and the sinuses coccobacillus found in the normal flora of cats were normal. and dogs. Human infection secondary to P. multocida usually involves contact with ani The patient was treated with timentin and mal secretions such as a bite or a lick. Pasteurel gentamicin intravenously and gentamicin topi la multocida has been implicated in a variety of cally. Pasteurella multocida was grown from both infections, including skin, bone and joint, pul a blood culture and drainage from the eye. monary, cardiovascular, and central nervous Intravenous antibiotics given for six days were system infections. 12 Ocular infections caused followed by amoxicillin orally for eight days. by P. multocida, however, are rare. A review The patient was able to open his left eye on the of the literature shows only nine cases third day of treatment. Follow-up examination of P. multocida ocular infections reported to showed complete resolution of the edema and date. We studied a case of orbital and perifull extraocular movements. Final visual acuity orbital cellulitis and conjunctivitis caused by remained R.E.: 20/70 and L.E.: 20/400. The P. multocida. afferent pupillary defect resolved. On further questioning, the patient admitted having a dog An 80-year-old man with a history of extraat home that frequently licked the patient's capsular cataract extraction with an intraocular hands and occasionally his face. lens implant in the left eye (four years previ ously), bilateral chronic open-angle glaucoma, Human infections from P. multocida usually and best-corrected visual acuity of R.E.: 20/70 result from direct inoculation through bites, and L.E.: 20/400 complained of pain and swell but can stem from contact with animal secre ing in the left eye of 24 hours' duration, associ tions. Ocular infections caused by P. multocida ated with copious amounts of green discharge. are extremely rare. Previously reported cases He denied any visual disturbance, but endinclude an 11-year-old girl who suffered a cat stage glaucoma in the affected eye made inter scratch to her eye and developed endophthalpretation difficult. No history of trauma to the mitis, 3 a 44-year-old woman who developed eye was noted. a corneal ulcer with hypopyon after her eye Results of physical examination disclosed a was bumped by her pet dog, 4 a 10-year-old boy