Follicular Keratoconjunctivitis, Pharyngitis, and Pseudomembrane in an Eyecare Provider

This 67-year-old male eyecare provider presented with a four-day history of irritation, blurring, and injection in his right eye. His symptoms and signs had become progressively more severe. In the past two days, he had experienced a significant increase in mucous discharge in the affected eye. He also reported recent onset of similar signs and symptoms in the contralateral eye. In addition to his ocular signs and symptoms, the patient reported recent-onset tenderness of his right preauricular node and flu-like symptoms of pharyngitis. Additional history revealed that approximately one week prior to his symptoms, he had diagnosed and treated adenoviral keratoconjunctivitis in one of his own patients.

Visual acuities with correction were OD 20/30 and OS 20/20. Biomicroscopy revealed bilateral injection, which was significantly more severe in the right eye. Punctate keratitis was present in the right eye. The tarsal conjunctiva of the right inferior fornix was covered with the pseudo membrane seen in this image. Palpation of the preauricular nodes revealed bilateral enlargement and tenderness that was much more severe on the right side.

The initial diagnosis was adenoviral keratoconjunctivitis, also known as epidemic keratoconjunctivitis (EKC). This diagnosis was based on case history and clinical findings that were very consistent with the diagnosis. The one-week latency period between exposure to the infected patient and onset of his own signs and symptoms was consistent with EKC, often caused by human adenovirus serotype 8 as well as 19 and 37.^1,2 Clinical illness typically lasts for seven to 21 days and is usually self-limited. Keratitis and subepithelial infiltrates often develop within days of onset, may persist for months, and in many cases impact visual acuity.³ Other potential tests for EKC include an adenovirus detector and polymerase chain reaction (PCR) for adenovirus. A study by Sambursky et al showed that the detector is 88% sensitive and 91% specific in detecting adenoviral conjunctivitis.⁴

Eyecare facilities are a common site for exposure to EKC. For instance, the Centers for Disease Control and Prevention (CDC) reported a four-state outbreak of EKC from 2008 to 2010.⁵ The sites ranged from a neonatal intensive care unit (NICU) to ophthalmology and optometry clinics. One reason that such outbreaks occur is that adenoviruses associated with EKC are very hardy and may persist on surfaces for up to 30 days. The complications from EKC can severely impact vision and quality of life. In a 2008 Minnesota outbreak, 53% of patients developed keratitis or corneal erosions, 41% had membranous conjunctivitis, and 40% showed some degree of decreased visual acuity. These patients often required additional and prolonged care for extended periods of time.⁵

There are currently no antiviral agents that are effective against EKC.⁵ Anti-herpetic agents have been shown to be ineffective against this condition. In our case, the patient was ultimately treated with topical 0.5% povidone iodine solution.⁶ Povidone iodine is a broad-spectrum antimicrobial that kills bacteria, fungi, viruses, and protozoa. It kills microbes by destroying microbial protein and DNA.⁷

Melton and Thomas reported successfully treating more than 200 cases of EKC with povidone iodine.⁶ Gloving is essential to prevent spread to the provider or to other patients. The standard protocol is to instill a topical anesthetic in the affected eye and then instill the povidone iodine into the fornix. The virus is commonly found on periocular tissues, so use a cotton ball to scrub the lids and surrounding skin with excess povidone. After 60 seconds, thoroughly irrigate the eye with sterile balanced saline.

In addition to the inherently inflammatory nature of EKC, povidone is very irritating, so prescribe a topical steroid to minimize post-procedure inflammation. If pseudomembranes form, they must be removed to prevent potential formation of symblepharon. After instilling a topical anesthetic, use blunt-tipped forceps to peel away the membrane, then instill a topical antibiotic/steroid. Frequent follow up is indicated for the first few days after removing membranes, as they may recur. In the case of this patient, repeat membrane removal was necessary in the initial (right) eye.

Educate affected patients and anyone living in the same home regarding the extremely contagious nature of this condition and the absolute necessity to avoid passing it along. Alcohol has virtually no impact on adenoviruses, so it is essential that home surfaces and clinic surfaces be regularly decontaminated using a viricidal cleaning/disinfecting agent.

NB: The patient is the author.

1. Grewal R, Jones R, Arango C, MD. Conjunctivitis with a Pseudomembrane. Available at https://www.consultant360.com/articles/conjunctivitis-pseudomembrane . Accessed on Sep. 7, 2019.
2. Pihos AM. Epidemic keratoconjunctivitis: A review of current concepts in management. J Optom. 2013 Apr;6:69-74
3. Bawazeer A. Epidemic Keratoconjunctivitis (EKC). Available at https://emedicine.medscape.com/article/1192751 . Accessed on Sep. 7, 2019.
4. Sambursky R, Tauber S, Schirra F, Kozich K, Davidson R, Cohen EJ. The RPS adeno detector for diagnosing adenoviral conjunctivitis. Ophthalmology. 2006 Oct;113:1758-1764.
5. Adenovirus-Associated Epidemic Keratoconjunctivitis Outbreaks — Four States, 2008–2010. Centers for Disease Control and Precention Mortality and Morbidity Weekly Report. 2013 Aug 16;62;637-641. Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6232a1.htm . Accessed on Sep. 7, 2019.
6. Melton R, Thomas R. Stop EKC with a 'Silver Bullet.’ Rev Optom. 2008 Nov;145. Available at https://www.reviewofoptometry.com/article/stop-ekc-with-a-silver-bullet . Accessed on Sep. 7, 2019.
7. Myers M, Gurwood A. Povidone iodine: useful for more than preoperative antisepsis. Primary Care Optometry News. February 2004.