H16.251-253 Phlyctenular Keratoconjunctivitis

Phlyctenlar keratoconjunctivitis is a form of bacterial hypersensitivity-mediated corneal disease.  Phlyctenular keratoconjunctivits is also called phlyctenulosis and other possible etiologies include tuberculosis and Chlamydia.

In most patients, the condition is the result of a reaction with staphylococcal cell wall antigen (i.e., adverse reaction to toxic proteins found on the ocular surface in chronic blepharoconjunctivitis).  

The histopathological changes in phlyctenular keratoconjunctivitis begin with the body’s immune response to the microbial antigens.  First, accumulations of lymphoid tissue form nodules on the bulbar conjunctiva known as phlyctenules.  Then, the conjunctiva surrounding the phlyctenules becomes hyperemic.

Conjunctival phlyctenules may persist for several weeks and are usually self-limiting.  However, they may ulcerate as the disease progresses but usually they heal without scarring. In more severe presentations, the conjunctival phlyctenules migrate into the cornea and are then called corneal phlyctenules.

Functional Damage to the Eye

• Decreased visual acuity can occur as a result of the compromised corneal epithelium

The main goal of the diagnostic evaluation in a patient with phlyctenular keratoconjunctivitis is to accomplish the following:

• To establish the diagnosis of phlyctenular keratoconjunctivitis
• To determine any inciting etiologies
• To prescribe appropriate therapy
• To prevent complications

To obtain the information required to determine a clinical diagnosis of phlyctenulosis and prescribe a treatment program, the following service components of a medical eye examination should be performed:

• Patient history
• General medical observation
• Adnexal examination
• External ocular examination with biomicroscopy

In children and young adults, a purified protein derivative (PPD) tuberculin skin test should be considered in the diagnostic evaluation.  If tuberculosis is supsected or if the PPD is positive, a chest X-ray is advised.

Patient History

Patients with phlyctenulosis may present with any of the following symptoms:

• Watery eyes
• Red eyes
• Ocular discomfort
• Photophobia
• Eye pain
• Blepharospam
• History of previous episodes
• History of styes or chalazion

External Ocular Examination with Biomicroscopy

Patients with phlyctenulosis may present with abnormal clinical signs in any of the following anatomical areas:

• Tear film
• Conjunctiva
• Cornea

There is no classification system for phlytenular keratoconjunctivitis.

Since phlyctenular keratoconjunctivitis is a hypersensitivity reaction to microbial toxins commonly seen with chronic staphloccocal blepharoconjunctivitis, treatment options must include treating these inciting conditions.

Palliative Treatment

• Lid hygeine regimen
• Artificial tears for comfort

Pharmacologic Treatment: Topical Medications

• Steroids in the presence of conjunctival involvement (i.e. Pred Forte q.i.d)
• Antibiotic in the presence of bacterial corneal ulcer (i.e. fluoroquinolones q.i.d)
• Antibiotic ointment (i.e. Erythromycin or Bacitracin qhs)
• Cycloplegic in severe corneal involvement
  • Homatropine 2% or 5%  t.i.d. – q.i.d.
  • Scopolamine 0.25%  b.i.d. – q.i.d.

Pharmacologic Treatment: Oral Medications

• Oral antibiotic (i.e. Doxcycline 100 mg p.o. q.d. to b.i.d or Erythromycin 250 mg p.o. q.d. to b.i.d.) 

Systemic Treatment

• If the PPD or chest X-ray is positive for TB, refer the patient for further management of the the systemic cause

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