BASICS

DESCRIPTION

Toxic keratoconjunctivitis is an inflammation of the bulbar and palpebral conjunctiva with corneal involvement due to exposure to foreign substance(s).

RISK FACTORS

• Use of topical ophthalmic medications, eye cosmetics, and contact lenses. Further, periocular molluscum contagiosum

• Exposure to environmental irritants

GENERAL PREVENTION

Avoidance of known irritants

PATHOPHYSIOLOGY

Nonantigenic induction of lymphocytes resulting in mitotic and lymphoblastic transformation

ETIOLOGY

• Exposure to environmental irritants, topical ophthalmic medications, contact lenses and solutions, and eye cosmetics

• Prolonged use of ophthalmic medications including glaucoma medications (e.g., brimonidine, apraclonidine, pilocarpine), antivirals (e.g., trifluridine), antibiotics (e.g., neomycin, gentamicin), and cycloplegics (e.g., atropine, homatropine)

• Preservatives in ophthalmic medications and solutions(i.e., benzalkonium chloride)

• Preservative-containing soaking solutions and enzymatic cleansers in contact lens wearers

• Proteins that spill from molluscum contagiosum lesions

DIAGNOSIS

HISTORY

Ocular redness, burning, irritation, and tearing with gradual onset from initial exposure to irritant or use of ophthalmic agent

PHYSICAL EXAM

• Diffuse conjunctival injection associated with a follicular response

• Follicles are enlarged and inflamed and mostly noted in the inferior fornix and palpebral conjunctiva

• Punctate epithelial staining of the cornea

• Chemosis

• Mild periocular erythema or edema

• Periocular molluscum contagiosum lesions: Elevated, round, white lesions with an umbilicated center

DIAGNOSTIC TESTS & INTERPRETATION

Pathological Findings

True lymphoid follicles that contain germinal centers with lymphoblasts

DIFFERENTIAL DIAGNOSIS

Allergic, bacterial, or viral conjunctivitis, dry eye, blepharitis, and contact lens overwear

TREATMENT

MEDICATION

First Line

• Avoid exposure to, or discontinue use of, the offending agent, if possible

• Preservative-free artificial tears 4–8 times daily

• Artificial tear ointment at bedtime as needed

Second Line

• Mild topical steroid may be considered in severe cases that are not responsive to first-line therapy

– Treatment with topical steroid should be initiated by an eye care provider.

ADDITIONAL TREATMENT

General Measures

• Identification and removal of offending agent

• Contact lens holiday. Use of another contact lens-care solution when contact lens use is resumed

Issues for Referral

• Failure to respond to treatment

• Referral to an eye care provider when there is visual impairment

SURGERY/OTHER PROCEDURES

Curettage or excision of molluscum contagiosum lesions

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Approximately 1 week following the initiation of treatment, although follow-up should be based on severity of disease and comorbidities

– When glaucoma medications are stopped, closely monitor intraocular pressure

Patient Monitoring

Monitor vision. With topical steroid use, monitor intraocular pressure and intraocular lens

PATIENT EDUCATION

• Risks of topical steroid use include glaucoma, cataract formation, and predisposition to infection. Treatment with topical steroid should be a short-term treatment only.

• Patients should be advised to follow up sooner than advised if there is a progression in symptoms or if symptoms are accompanied by visual impairment.

PROGNOSIS

Generally good

COMPLICATIONS

Elevation of intraocular pressure when glaucoma medications are stopped

ADDITIONAL READING

• Dart J. Corneal toxicity: The epithelium and stroma in iatrogenic and factitious disease. Eye (Lond.) 2003;17:886–892.

• Lindquist T. Conjunctivitis: An overview and classification. In: Krachmer J, Mannis M, Holladay E, (eds). Cornea, 2nd ed. Elsevier Mosby, 2005.

• Rubenstein JB, Virasch V. Conjunctivitis: Infectious and noninfectious. In: Yanoff Duker, (ed). Ophthalmology, 3rd ed. Mosby, 2008.

• Wilkerson M, Lewis RA, Shields MB. Follicular conjunctivitis associated with apraclonidine. Am J Ophthal 1991;111:105.

• Wilson FM II. Adverse external ocular effects of topical ophthalmic therapy: An epidemiologic, laboratory, and clinical study. Trans Am Ophthalmol Soc 1983;81:854–965.

• Wilson FM II. Adverse external ocular effects of topical ophthalmic medications. Surv Ophthalmol 1979;24:57.

CODES

ICD9

370.49 Other keratoconjunctivitis, unspecified

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