There was a very interesting medical story on all the main British TV channels recently. It was about a young female medical student who developed a serious problem with one eye, which caused recurrent iritis. (1). As I well remember, being a medical student was very challenging, but when you have to put eye drops in your eye every hour, it must have been almost impossible to work and study. Iritis, or anterior uveitis to use its correct name, is very painful and affects your eyesight, and there are lots of conditions that can cause it. She was fully investigated for infections and autoimmune diseases and other rarer conditions, but nothing was found. The treatment is steroid drops into the eye, which does control the symptoms, but the condition kept  returning. The high steroid dose caused a cataract to develop, which had to be removed surgically. Even after this the doctors still couldn’t find a cause. She was considering having her eye removed as she was in so much pain. But then the doctors made a  breakthrough. 

The only way currently to diagnose any infection is to take a swab of the infected area, and smear it on to a petri dish containing a nutrient. Then you have to incubate it for at least 24 hrs, after which the pathology worker can look at it and see what has grown. Sometimes one bug is grown, sometimes several, and an expert has to be able to identify them and work out whether any of these could be causing the symptoms the patient has. This process has to be gone through whatever the problem is, so that if you have a cut which isn’t healing for instance, a swab has to be sent off, or, for really serious things like sepsis, a series of swabs including specimens of blood  have to be taken, but the doctors have to treat anyway while waiting for the result. They do this on the basis of current expert clinical opinion, but doctors can easily get this wrong, and choose an antibiotic which doesn’t work. So a lot of time has been wasted, with the patient getting sicker and sicker. This can be a life and death choice with urgent conditions like sepsis.

So this isn’t a quick test; results can take a week or more to come back. Sometimes no organism is grown at all and the patient still hasn’t got better. This might happen if the cause is a virus for instance. So over the years doctors, especially GPs, have stopped doing swabs, and use the most likely antibiotic for the condition they are seeing clinically. In the case of this young doctor, no swab had ever grown any bacteria that might cause the condition. 

Her  case was so important – a young doctor facing having her eye removed at the beginning of her career and just before she was due to get married, – that all the stops were pulled. In a last ditch effort, the doctors used an experimental department in Great Ormond Street hospital, which uses a new method of diagnosing infections – metagenomics. This is a field of biology which focuses on studying all the DNA (the genome) of organisms such as microbes, and their structure and function. It is often used to study a specific community of micro-organisms, such as those residing on human skin, in the soil or in a water sample. So It provides a means of studying microbial communities in situ, without having to make them multiply themselves on a petri dish. 

This method will recognise the DNA of any microbe. Miraculously, the scientists identified a bug which no one had foreseen. It was leptospira, a zoonotic infection (one transmitted by animals), not normally found in Europe. It is known to cause iritis, although not frequently diagnosed according to one study in 2022. (2) .The organism is well reported worldwide, as leptospirosis is also known as Weil’s disease, which I learnt about in medical school 60 years ago – it causes liver disease. Anyway there is a well-known treatment for it, and she had a three week course, and her vision quickly cleared, and the pain went away. It appeared that she may have contracted  it when swimming in the Amazon on holiday five years previously. The patient was over the  moon and she was able to have a wonderful wedding, and to continue her career. That was a fantastic  break through.

It seems that eventually this sort  of procedure could be developed further, so that it can be used in many more cases. We should be able to identify a  bacterial  or viral cause of any infection very quickly in the future. I believe the method is already being scaled up so that other hospitals will be able to use it in the next few years. 

So now from the sublime to the ridiculous – or at least from a very serious infection in the eye, to a much more mundane one – conjunctivitis. it is a condition I developed in the last eighteen months, which is of course why I am particularly interested in it. Infection of the conjunctiva, that is the outer lining of the eye, is common, because it is the part of the eye totally exposed to anything damaging in the atmosphere. It generally clears up quite quickly, with or without treatment because of the action of the body’s immune system. Recurrent conjunctivitis is quite rare, although it can be associated with blepharitis, where the eyelids are infected and this does recur. The mainstay of treatment is good lid hygiene done by the patient. In the past, GPs used to treat conjunctivitis with antibiotic eye drops if it was severe, but now pharmacists, optometrists and nurses are often trained in when to treat with antibiotics or not. But in general it is not given any priority, and patients tend to be shunted from one health care professional to another. It is a bit of a “sink” condition in that respect. 

Conjunctivitis is common in all ages, especially children. But as people get older there can be age degeneration of the fatty tissue of the eyelid causing the eyes to be more sunken, and a pouch can develop  behind the upper eyelid deep in the tissues, and this can trap bacteria causing severe recurrent bacterial conjunctivitis.  This condition is called Giant Fornix Syndrome (fornix is Latin name for “arch”) and was described 20 years ago at Moorfields hospital in London. (3) But is the medical profession aware of this? Not in my experience. Sufferers  (they are usually women between the ages of 75 and 90) try to get treatment for their “sticky eyes” and usually get told to clean their eyelids properly. Unfortunately the symptoms tend to get worse, and steroid drops have to be used. It is an annoying and sometimes painful condition which causes very blurry vision due to the mucus discharge and discomfort. But nearly all people with this condition have to wait up to 2 years to get anything done.  I waited over a year, and I am a retired GP, who was already seeing hospital eye doctors because of another unrelated condition. Some people get permanent damage to their eyes before referral (corneal vascularization and scarring, and some corneal perforation or thinning) so it is not entirely benign.

No swabs seem to be done to see which infection it is, which would definitely give an indication that there is something more to it than it seems, as bacteria grow there that never grow anywhere else.  The only health professionals in the community that can do eye swabs are GP’s, as they are trained in bacteriology and infections, which Optometrists and Pharmacists aren’t, and are never likely to be. But at the moment many GPs refuse to see patients with eye problems unless they have seen an Optometrists first. 

The unusual thing about this disease is that there is a very simple operation which will cure it completely in most cases. It involves re-fashioning the lids, in an operating theatre under local anaesthetic to get rid of the the pouch, which takes about 45 minutes.

So why is the condition not known about?  Only, I believe, because conjunctivitis  is such a common condition, not serious, and is not treated well by any of the various health professionals who are trained to deal with it.  And the clientele – elderly women – aren’t considered interesting to the media, so no stories have been done to publicise the condition. 

And finally, to link these two conditions, if the metagenomics revolution takes off, then there would be no need for the complicated pathway to get antibiotics for this infection, when, often by the time the result has come back from the lab, the infection has either changed or gone away temporarily.  You could get an answer the same day, so treatment should be always be much more accurate. And this would be true for so many other conditions. I do hope it can be developed soon!

In the meantime I would like use this column to do a sort of awareness campaign for elderly ladies with sticky painful eyes. if you, or some-one you know in the relevant age group, suffers from such symptoms, one of the things you could ask your GP to do, is to send off an eye swab to the bacteriology department. If bacteria are grown and identified, then the appropriate treatment can be given. But if it recurs several times, then an urgent referral should be made. I was told that no-one gets frequent bacterial  infections without an underlying cause. But if eye swabs aren’t done, then doctors will dismiss it as a viral infections or blepharitis which you have to put up with. 

  How common is it? We don’t know. My eye specialist tells me he has done six such operations in his present job – not very many.  But then he hardly gets any cases referred with possible GFS, if my experience is anything to go by, and has a huge list of patient waiting to be seen.  And even different departments of the eye hospital may not know about it, so the doctors there do not refer to Oculoplastics (the subspecialty which deals with this condition). Maybe it is better known in other parts of the country, I don’t know. But I definitely think there is a need for more education for all levels of health care including all hospital specialists, resident doctors in hospitals, and especially including registrars in general practice, who are quite likely to come across eye problems like this that, at the moment, they neither want to see or to treat. 

(1) https://uk.news.yahoo.com/doctor-eye-removed-sight-saved-060829577.html?

(2) https://www.aaojournal.org/article/S0161-6420(04)00528-7/abstract

(3) https://pmc.ncbi.nlm.nih.gov/articles/PMC9773111/