Bilateral Giant Fornix Syndrome Associated with Serratia Marcescens

An 82-year-old woman with macular degeneration receiving intravitreal bevacizumab, presented with 5-months history of muco-purulent blepharo-kerato-conjunctivitis, resistant to multiple topical antibiotics. Visual acuities were 20/25 right and 20/30 left. She had patent nasolacrimal systems, bilateral blepharoptosis, deep superior fornices (21mm right, 22mm left) with muco-purulent discharge, upper tarsal papillae, and punctate keratitis. Bilateral giant fornix syndrome (GFS) was diagnosed, and forniceal swabs grew Serratia marcescens and Pseudomonas aeruginosa, despite current use of intensive topical moxifloxacin. Topical preservative-free Povidone-Iodine 5% twice-daily, two-hourly weaning course of Prednisolone acetate 1% and Ciprofloxacin 250 mg twice-daily were added with complete resolution within 1 week and no recurrence after 3 months. Serratia conjunctivitis has not been previously reported in association with GFS. Conjunctival flora alteration following previous peri-procedural antibiotics and antiseptics, in the setting of a large fornix with redundant, inflamed conjunctiva, may explain the colonization with this opportunistic organism. Topical povidone-iodine 5% appears to be effective for multi-drug resistant opportunistic Serratia conjunctivitis in association with GFS.