Consultation section: Cornea
I agree with my colleagues and their comments concerning the extensive differential diagnosis concerning this case. In my opinion, this is a case of chronic, unilateral, keratoconjunctivitis with blepharitis and chalazion consistent with what is known as ocular surface Splendore-Hoeppli Phenomenon.
Extensive workup, including numerous cultures and several biopsies of the bulbar conjunctiva and chalazion material, did not reveal any offending agent. Specifically, molluscum contagiosum, atypical mycobacterium, and numerous viral, fungal, and bacterial cultures did not identify any positive organism. Conjunctival and the chalazion biopsies did not reveal a specific granulomatous reaction. Most biopsies revealed typical conjunctival epithelium with subconjunctival tissue element, along with few polymorphonuclear neutrophils, without eosinophilic reaction and very few lymphocytes. Blood work for collagen vascular diseases and sarcoidosis was noncontributory.
The patient was treated with topical ivermectin gel 0.1% applied twice a day to his eyelids for 1 month without any obvious improvement. Two additional 14-day courses of oral amoxicillin–clavulanate (Augmentin) as well as a 10-day course of oral acyclovir were not of any overt benefit to his ocular condition. He responded very well with resolution of his symptoms and signs to a low-dose topical fluorometholone 0.1% ophthalmic suspension, with a very slow taper over the course of 3 months; however, upon cessation the symptoms reoccurred slowly over the course of 3 months, requiring fluorometholone again. I am planning to start topical tacrolimus 0.03% for the next of rebound of inflammation.© 2019 by Lippincott Williams & Wilkins, Inc.