Stellate tarsoconjunctival lesions in ocular adenoviral infection

Case report

A 21 year old man presented with a 1 week history of bilateral red, painful eyes associated with photophobia, blurring of vision, and a mucous discharge. There was no history of respiratory tract infection, genitourinary symptoms or infectious contacts. Best corrected visual acuities were 6/6 bilaterally. On examination he was found to have unusual creamy white stellate lesions on his tarsal plates (Fig 1). These focal lesions were, on average, 1 × 1 mm in size and subepithelial in nature. In addition, both conjunctivae were hyperaemic, subepithelial corneal infiltrates were present, and there was a golden yellow brown mucous discharge.

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Figure 1

Creamy white stellate lesions on the tarsal plates.

A clinical diagnosis of adenoviral keratoconjunctivitis was made. The enzyme immunoassay test (Adenoclone, Cambridge Bioscience, Worcester, MA, USA) confirmed the presence of adenovirus in conjunctival swabs. Micro Trak HSV-1/ HSV-2 culture confirmation/typing test (Syva Co, Palo Alto, CA, USA) failed to isolate HSV from either eye and polymerase chain reaction (PCR) to detect Chlamydia trachomatis was also negative. No bacterial species were isolated.

The patient was initially treated with topical chlortetracycline ointment four times a day and prednisolone drops three times a day, to each eye. When reviewed 1 week later, there was a marginal improvement in symptoms, although best corrected visual acuities had fallen to 6/9 bilaterally. The topical prednisolone was replaced by fluorometholone and the chlortetracycline was discontinued. Two weeks later, the patient's symptoms had markedly improved and the topical steroid was reduced in frequency and then stopped. The visual acuities had by this time returned to 6/6 in both eyes. However, both the white tarsal stellate lesions and the corneal subepithelial infiltrates have persisted 2 months after complete resolution of symptoms.

Comment

Corneal subepithelial infiltrates are a known complication of adenoviral conjunctivitis.¹ These lesions usually become apparent within 10–14 days after onset of symptoms and in some cases may persist for months or even years after the acute phase of the infection. Although the opacities gradually fade with time, those associated with reduced visual acuity may require a course of topical corticosteroids. However, return of the opacities can be seen with discontinuation of the corticosteroids.² In cases of prolonged follicular conjunctivitis, equivocal ocular signs, or suspected superimposed infections, specimen culture is an important tool to aid diagnosis.^3,4

Although small star-shaped ulcers (herpetic stellates) have been documented as a clinical manifestation seen in herpes simplex eye infections,⁵ these lesions have been confined to the corneal epithelium. To our knowledge, no such lesions have been documented in the tarsoconjunctiva, either in adenoviral or herpes simplex viral conjunctivitis, although pseudomembranes and symblepharon can occur.