Giant Fornix Syndrome - An Overview

Introduction

The disorder known as Giant Fornix Syndrome (GFS) is an uncommon form of infectious inflammation affecting the superior and, less frequently, the inferior conjunctival fornices. It is characterized by excessively deep fornices, a large recurring bacterial infection of the conjunctivae, and age-related levator aponeurosis degeneration. Typical symptoms include chronic conjunctivitis, ptosis from underlying superior conjunctival irritation, and purulent proteinaceous discharge. The best course of action involves a variety of techniques, including surgical, steroidal, antibiotic, and antimicrobial ones.

What Is Giant Fornix Syndrome?

Giant fornix syndrome (GFS) is a rare chronic inflammatory illness characterized by recurrent purulent conjunctivitis. GFS generally affects older people with a deep superior fornical architecture, which puts them at risk for recurrent conjunctival infections. Chronic conjunctival discharge is the clinical hallmark of GFS, which is frequently accompanied by subsequent corneal and eyelid involvement.

The most frequent clinical manifestations of GFS are:

• Mucopurulent conjunctival discharge.

• Conjunctival inflammation.

• Pseudomembrane development in the conjunctival fornices.

• Ptosis.

• Ocular surface disease.

• Keratitis.

• Corneal scarring.

Corneal abnormalities might lead to eyesight loss if neglected. Giant Fornix Syndrome often manifests between the seventh and ninth decade of life, with a median age of 75.

What Is the Pathophysiology Behind Giant Fornix Syndrome?

Giant fornix syndrome is a long-lasting staphylococcal pseudomembranous conjunctivitis that develops in the large upper conjunctival fornices of the elderly. The condition is brought on by a protein called coagulum nidus that becomes infected. Patients arrive with conjunctivitis that does not respond to medical intervention and repeated episodes of purulent ocular discharge. Some people's corneas may vascularize and undergo subsequent scarring. All of them have big superior conjunctival fornices, which are considered to be caused by the levator muscle aponeurosis dislocating with aging. This causes the fornix to dig deeper since it pulls on the conjunctiva rather than the tarsus.

The onset of the illness starts with moderate conjunctivitis that may result in protein exudation from irritated tarsal conjunctiva. Bacterial proliferation results from the sequestration of the bacteria-covered proteins in the deep superior fornix. Further protein is released from the chronically inflamed conjunctiva due to bacterial growth. A pseudomembrane may eventually develop from the persistent protein exudation.

A blocked lacrimal duct may worsen the situation by increasing the bacterial burden in the tear pond. In such a hazardous environment, the ocular surface may experience spontaneous perforation, permanent vascularization, and scarring.

What Are the Symptoms Associated With Giant Fornix Syndrome?

The predominant features of giant fornix syndrome are:

• Purulent conjunctivitis is chronically recurrent and discharges profusely.

• Pain.

• Redness.

• Inflammation.

• Dryness.

• Tearing.

• Burning sensation.

• A feeling of a foreign body and impaired vision.

What Pathogen Is Associated With Giant Fornix Syndrome?

Staphylococcus aureus appears to be the main culprit and the ineffectiveness of topical medicines at low doses in alleviating symptoms points to bacterial sequestration within the Fornical coagulum.

What Are the Risk Factors Associated With Giant Fornix Syndrome?

The following are the risk factors associated with Giant Fornix Syndrome:

• A significant risk factor is age, with GFS frequently manifesting in older individuals.

• The higher occurrence of GFS in females suggests a female sex preference.

• A patient is more likely to develop GFS when commensal organisms, most frequently Staphylococcus aureus, chronically colonize their eyelashes and conjunctival fornices.

What Are the Diagnostic Tests Associated With Giant Fornix Syndrome?

1. Bacterial Culture - A significant bacterial load is usually seen in GFS patients' purulent conjunctival discharge, which may be cultured. The two most often isolated commensal species, Staphylococcus aureus and Staphylococcus epidermidis are regularly seen.

2. Immunophenotypic Examination - It is an inflammatory process confirmed by immunophenotypic examination of the purulent conjunctival discharge.

3. Biopsy - A biopsy of the conjunctiva would show severe chronic inflammation, a profusion of plasma cells, and tiny, well-differentiated lymphocytes with germinal centers.

What Are the Treatment Modalities Associated With Giant Fornix Syndrome?

The following are the treatment modalities that are associated with Giant Fornix Syndrome:

• Strong topical steroids (such as Prednisolone, 1 percent) should be used hourly for several weeks as part of the recommended therapy.

• A suitable systemic antibiotic (Azithromycin, Ciprofloxacin, or Flucloxacillin) should also be administered to patients, along with a topical antibiotic (Ofloxacin or Chloramphenicol). Depending on how persistent the coagulum development is, the systemic antibiotic might need to be given anywhere between 10 and 30 days.

The following are the other treatment options:

• Diluted antiseptic swabs and washes.

• Using manual swabs to lower the bacterial burden.

• Antibiotic Injections into the Subconjunctiva.

• Rinse with an antimicrobial solution.

• Ocular drops with autologous serum.

• Treatment of eyelashes with hypochlorous acid.

Regularly using a cotton swab to sweep the upper fornix can help to eliminate the protein coagulum during the first few days of therapy. Superior fornix excision and, in certain situations, lacrimal surgery may be needed for surgical therapy if conservative treatment fails.

What Are the Complications Associated With Giant Fornix Syndrome?

The success rate of corneal repair after non-traumatic perforation is lower.

The following conditions can result from untreated corneal perforations are:

• Blindness.

• Endophthalmitis.

• Permanent glaucoma.

• Corneal ulcer.

• Corneal perforation.

Conclusion

This illness is chronic, recurring, and challenging to treat. The prognosis is based on early diagnosis and treatment effectiveness. In extreme cases, this illness may result in corneal perforations and ulcers if left to progress without treatment. Though they should not be used to rule out big fornix syndrome, CT scans may help diagnose it. Less intrusive procedures could reduce the risk of surgical adverse effects if fewer symptoms occur.

When treated with systemic antibiotics and high-dose antibiotic steroid combination eye drops, mild illnesses look to be successfully curable in a few weeks. Similar therapies can also treat mild to moderate illnesses; however, lifelong treatment of a low-dosage antibiotic or steroid combination eye drop may be necessary to avoid recurrence. A combination of vigorous povidone-iodine washes, physical disruption of the coagulum using a cotton swab, antibiotics, and steroids may be used to treat or cure mild, moderate, and perhaps severe illness in a few weeks.