PHLYCTENULAR KERATO-CONJUNCTIVITIS

October 16, 2006 Dr Sanjay Shrivastava 2

Definition

• Phlyctenular kerato-conjunctivitis (PKC) is characteristic nodular affection occurring mainly in children as an allergic response of the corneal and conjunctival epithelium to endogenous toxin to which the tissue has become sensitized. Phlycten means Blister.

October 16, 2006 Dr Sanjay Shrivastava 3

Epidemiology

• World-wide, sporadic. Most commonly found in the young in the first and second decades of life with peak between ages 3 and 15. Usually higher incidence in girls than in boys. Most commonly found in the undernourished who live in poor and overcrowded unhygienic conditions, not exposed adequately to sunlight. More common in poorer quarters of the cities, affecting all races.

October 16, 2006 Dr Sanjay Shrivastava 4

Etiology

• Phylectenules are an allergic phenomenon, a reaction of the hypersensitive of epithelium of the cornea and conjunctiva to any protein; the reaction is essentially non-specific but in the majority of clinical cases due to tubercular proteins.

• Staphylococcus aureus may also act in this way in highly sensitive patients. May also occur in patients with metastatic endogenous gonococcal conjunctivitis.

October 16, 2006 Dr Sanjay Shrivastava 5

Pathology

• Granulation tissue with fibroblasts and blood vessels are common in the areas of epithelial necrosis and ulceration. Lesion consists of leucocytes into the deeper layers of the conjunctiva. Central cells are polymorphs, the peripheral mononuclear and occasionally giant cells. Neighboring blood vessels are dilated with proliferation of their endothelium.

October 16, 2006 Dr Sanjay Shrivastava 6

Pathology … contd

• Occasionally lesions resolves, but usually necrosis takes place, the epithelium sloughs off over the apex of the nodule and an ulcer forms, the epithelium heals without leaving any scar.

• An attack does not confer any immunity.

October 16, 2006 Dr Sanjay Shrivastava 7

Symptoms

• Simple Phlyctenular conjunctivitis has few symptoms. There is some discomfort and irritation associated with reflex lacrimation. In case of secondary bacterial infection, there is muco-purulent discharge. Photophobia in cases of corneal involvement.

October 16, 2006 Dr Sanjay Shrivastava 8

Signs

• Phlyctenulosis can affect any part of the ocular surface , including the cornea, limbus and conjunctiva.

I. Conjunctival Lesions (types)a. Conjunctival phlyctenules are raised amorphous , light pinkish to grayish nodules measuring 1 -2 mm in diameter. Nodule is usually near limbus but may be anywhere on the bulbar conjunctiva and rarely affect the palpabral conjunctiva.

October 16, 2006 Dr Sanjay Shrivastava 9

Signs ...contd

Congestion is limited around the phlyctens.

After 2 -5 days nodule becomes soft and ulcerate with necrosis.

b. Pustular Conjunctivitis – large phlycten with necrosis.

c. Miliary Phlyctenular conjunctivitis – Phlyctene in large numbers round the limbus.

Secondary infection with frank mucopurulent conjunctivitis is frequent.

October 16, 2006 Dr Sanjay Shrivastava 10

Signs … contd.

II. Phlyctenular Keratitis May develop de-novo or may spread from the conjunctiva due to anatomic continuity of epithelium

Types of Corneal Phlyctenular lesions a. Corneal nodule (Phlycten) – a gray nodule raised above the surface, a yellow ulcer forms if epithelium breaks.

October 16, 2006 Dr Sanjay Shrivastava 11

Signs … contd

Corneal phlyctens usually appear at the limbus and may migrate either to cornea or to conjunctiva .

b. When phlycten migrate on to the cornea, strands of superficial corneal blood vessels arising from the limbus follow the course of phlycten.

Superficial vascularized scar is typical after healing occurs.

October 16, 2006 Dr Sanjay Shrivastava 12

Signs …contd

The ulcer creeps on the corneal surface from periphery is called fasicular ulcer/keratitis.

A typical course of PKC last about two weeks.

c. Miliary Ulceration – multiple minute ulcers scattered over a portion of or

the whole of the cornea.

October 16, 2006 Dr Sanjay Shrivastava 13

Course

• Phlyctenular disease is extremely liable to relapses

October 16, 2006 Dr Sanjay Shrivastava 14

Diagnosis

Diagnosis is based on:

a. Clinical picture

b. Skin test for tuberculosis

c. Chest X- ray

d. Reduced resistance may also be investigated

e. In case of secondary infection – culture and sensitivity of conjunctival discharge

October 16, 2006 Dr Sanjay Shrivastava 15

Treatment

• Tuberculous Phlyctenulosis

a. Topical steroid – Prednisolon Acetate 1% six times for 1 week then taper.

b. Steroid + Antibiotic drops (in cases of secondary bacterial infection)

October 16, 2006 Dr Sanjay Shrivastava 16

Treatment … contd

• Non-Tuberculous Phlyctenulosis (Staphylococcus is commonest) – associated blepharitis and meibomitis should be treated with oral tetracycline and Antibiotic steroid ointment or drops for 2 – 3 times for several weeks. In case of children or pregnant women or nursing mothers Erythromycin is given in place of Tetracycline

October 16, 2006 Dr Sanjay Shrivastava 17

Phlyctenular Keratitis

• In case of Phlyctenular Keratitis broad spectrum topical antibiotics (Ciprofloxacin, Ofloxacin, Polymyxin B) are used for several days before corticosteroid therapy.

• Rare small corneal perforation may be treated by Cynoacrylate glue. Penetrating Keratoplasty for Corneal Scar after 6 months of subsidence of inflammation

• Cycloplegics are added