Systemic Minocycline Treatment of Methicillin-resistant Staphylococcus aureus in Giant Fornix Syndrome

Dear Editor, Rose [1] first reported on giant fornix syndrome which can be an unrecognized cause of chronic relapsing purulent conjunctivitis in elderly patients. Conjunctivitis in giant fornix syndrome usually presents with an upper capacious fornix, which is lodged with proteinaceous debris and colonized with bacteria, commonly Staphylococcus aureus [1]. Several previous reports have found that using broad spectrum topical antibiotics, systemic antibiotics, and topical steroids is effective [2]. We describe a case of methicillin-resistant Staphylococcus aureus (MRSA) chronic conjunctivitis in giant fornix syndrome that was recalcitrant to topical treatments but was successfully and rapidly treated after systemic minocycline treatment. An 82-year-old woman presented with chronic persistent mucopurulent conjunctivitis of the left eye. She had been treated unsuccessfully for 4 months. She was currently using topical chloramphenicol eyedrops and oxytetracycline ointment. She received cataract surgery on both eyes 18 months ago but did not have any other ocular history. The patient’s uncorrected visual acuity was 20 / 250 and intraocular pressures were within normal limits. Slit-lamp examinations showed thick coagulum and yellowish mucoid discharge at the conjunctival sac (Fig. 1A and 1B) and multiple conjunctival papillae and follicles. The corneal surface was irregular with diffuse punctate epithelial erosions, as seen in toxic keratopathy (Fig. 1C). By everting her upper eyelid, the superior fornix was revealed to be deep and filled with plenty of thick coagulum. Blepharoptosis due to age-related disinsertion of the levator muscle aponeurosis was greater in the left and the left eyelid was swollen (Fig. 1D). There were signs of blepharitis such as erythema and telangiectasis in both eyelids. The all lacrimal drainage systems were open and showed no pus drainages. A computed tomography scan of the orbit did not reveal any evidence of orbital cellulitis. Based on the clinical findings, giant fornix syndrome was diagnosed. A conjunctival culture was performed. The patient was administered topical moxifloxacin every 2 hours and 1% prednisolone acetate every 6 hours. Lid management using warm compression and cleanser was started. She refused any systemic antibiotics because she was already taking several other medications prescribed by other departments. One week later, conjunctival injection and pus drainage were slightly improved but still bothering her. The culture Korean J Ophthalmol 2016;30(5):394-395 http://dx.doi.org/10.3341/kjo.2016.30.5.394