Orbital Inflammation Developing from Epidemic Keratoconjunctivitis in an Adult
A 67-year-old man was referred to Oculoplastics after suffering from conjunctival injection and chemosis in the right eye for 4 days. Previously being diagnosed with EKC by another ophthalmologist, the patient had been treated with levofloxacin eye drops (Cravit®, Santen Pharmaceutical Co. Ltd., Osaka, Japan) and fluorometholone 0.1% eye drops (Flumetholon 0.1®, Taejoon Pharm Co. Ltd., Seoul, Korea). However, his symptoms were worsening even on medication, so orbital cellulitis was suspected and he was referred to our clinic. The patient had an ocular history of cataract operation – phacoemulsification and posterior chamber intraocular lens implantation – in both eyes 9 months ago. When he had a check-up 1 month ago, his corrected visual acuities were 20/20 in both eyes. He had a medical history of diabetes, but there was no other clinical evidence of any other systemic disease or a trauma.\nAt the point of referral, the patient's corrected visual acuities were 20/50 in the right eye and 20/20 in the left eye. His right eye was almost closed due to severe erythematous lid swelling, and he had marked conjunctival injection and chemosis. He complained of limited extraocular motility in horizontal gaze and diplopia in lateral gaze in the right eye. There was no relative afferent pupillary defect in the right eye. Intraocular pressure (IOP) was 22 mm Hg in the right eye and 9 mm Hg in the left eye by Goldmann tonometry. Slit lamp examination of the right eye showed diffuse bullous conjunctival chemosis, hyperemia, corneal edema, and mild anterior chamber reaction. Examination of the left eye was unremarkable (fig. ). A non-contrast orbital computed tomography (CT) scan displayed right periorbital infiltration and swelling, thickening of the right lateral rectus muscle, and mucoperiosteal soft tissue attenuation in the left maxillary sinus, leading to a diagnosis of right orbital cellulitis (fig. ). The patient was given intravenous cefmetazole (Cefmetazole®, SCD Pharm Co. Ltd., Seoul, Korea) 500 mg twice a day; oral amoxicillin 500 mg/clavulanate 125 mg (Augmentin®, Ilsung Pharmaceuticals Co. Ltd., Seoul, Korea) 3 times a day; levofloxacin (Cravit) eye drops, and fluorometholone 0.1% (Flumetholon 0.1) eye drops. His body temperature was 36.6°C, i.e. he was afebrile.\nFive days after the onset of symptoms, and 1 day after the systemic antibiotic treatment, anterior segment conditions and extraocular motility in the right eye did not improve. IOP increased to 32 mm Hg in the right eye, but it was normalized after using a topical IOP-lowering agent. Six days after the onset, and 2 days after the treatment with systemic antibiotics, chemosis and conjunctival injection were seen in the contralateral, left eye, while symptoms in the right eye did not improve.\nThree days after the treatment with systemic antibiotics, there was no improvement in the right eye. We started to consider the possibility of idiopathic orbital inflammation. As infection could not be excluded completely, the patient was given 1 dose of intravenous methylprednisolone 250 mg (solu-Medrol®, Pharmacia and Upjohn, USA) per day with systemic antibiotics. Eight days after the onset, and 1 day after the treatment with systemic steroid, there was improvement in lid edema, conjunctival injection, and chemosis in the right eye. Yet, no changes were seen in the left eye.\nSystemic antibiotics were discontinued because the possibility of an infection now seemed low. The patient continued on intravenous methylprednisolone 250 mg (solu-Medrol) per day and started on 20 mg oral prednisolone (Nisolone®, Kukje Pharm, Korea) twice a day. Nine days after the onset, 2 days after the treatment with systemic steroid, there was significant improvement in the lid swelling of the right eye, and conjunctival injection and chemosis in both eyes. His corrected visual acuities went up to 20/25 in the right eye and pseudomembranes were seen in both eyes. Oral prednisolone was continuously tapered by 10 mg per 2 days.\nTwo weeks after the onset, lid swelling of the right eye, conjunctival injection, chemosis, and corneal edema in both eyes were all gone. The patient's corrected visual acuities recovered to 20/20 in the right eye. The patient's limited extraocular motility in the right eye and diplopia also resolved (fig. ).