Keratoconjunctivitis

BASICS


DESCRIPTION


• Uncommon, usually unilateral, affects conjunctiva and/or cornea


• Seen more commonly in children and young adults


• Due to type IV hypersensitivity reaction to microbial agents


• Pinkish-white nodule at limbus involving conjunctiva and/or cornea


EPIDEMIOLOGY


Incidence


60–70% female


Prevalence


Unknown


RISK FACTORS


Blepharitis


Genetics


None


GENERAL PREVENTION


Treat blepharitis: lid scrubs


PATHOPHYSIOLOGY


Delayed type hypersensitivity to bacterial antigen


ETIOLOGY


• Staphylococcal infection


• Tuberculosis


Chlamydia, Candida, Coccidioides


COMMONLY ASSOCIATED CONDITIONS


Blepharitis


DIAGNOSIS


HISTORY


• Pain, photophobia, tearing, foreign body sensation, redness


– If cornea involved, symptoms more severe


PHYSICAL EXAM


• Conjunctival phlycten: small, round, elevated, yellow to white nodule near limbus


• Corneal phlycten: starts at limbus, can extend onto cornea, may have associated epithelial defect


DIAGNOSTIC TESTS & INTERPRETATION


Lab


Chest X-ray (CXR), purified protein derivative (PPD) if suspicious of tuberculosis (1)[C]


Imaging


CXR, PPD in suspicious cases


Diagnostic Procedures/Other


Corneal cultures if infectious keratitis suspected (1)[C]


Pathological Findings


Histopathology shows that nodules are composed of lymphocytes, histiocytes, and plasma cells.


DIFFERENTIAL DIAGNOSIS


• Rosacea keratitis


• Inflamed pinguecula


• Limbal herpes keratitis


• Microbial keratitis


• Nodular episcleritis


TREATMENT


MEDICATION


First Line


Treat underlying blepharitis: lid scrubs, artificial tears, antibiotic ointment (erythromycin or bacitracin) 4 times a day


Second Line


• Short course of topical steroid–antibiotic combination 4–6 times a day


• Systemic tetracycline 250 mg q.i.d. for 2–4 weeks (2)[C]


• Topical metronidazole


• Topical antibiotics if bacterial keratitis suspected


Geriatric Considerations


Side effects of long-term topical steroid use include cataract formation and glaucoma.


Pediatric Considerations


Tetracycline contraindicated in children. Substitute erythromycin 250 mg q.i.d.


Pregnancy Considerations


• Tetracycline contraindicated in pregnant or nursing women. Substitute erythromycin 250 mg q.i.d.


• Steroids are class C and of unknown safety in lactation.


ADDITIONAL TREATMENT


General Measures


Treat tuberculosis


Issues for Referral


Recurrent or causing corneal scarring


ONGOING CARE


FOLLOW-UP RECOMMENDATIONS


• Mild cases will resolve in 2–4 weeks.


• Follow patient weekly.


PATIENT MONITORING


If cornea involved, monitor for scarring or epithelial defect leading to melting.


PATIENT EDUCATION


Long-term treatment of blepharitis with lid scrubs, artificial tears, and ointment to prevent recurrence


PROGNOSIS


Overall good; if severe, may have residual corneal scarring leading to decreased vision.


COMPLICATIONS


Corneal scarring, decreased vision



REFERENCES


1. Robin JB, Schanzin DJ, Verity SM, et al. Peripheral cornea disorders. Surv Ophthalmol 1986;31:1–36.


2. Abu el-Asrar AM, Tabbara KF. Tetracycline treatment of phlyctenulosis. Ophthalmology 1994;101:1161–1162.

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Nov 9, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Keratoconjunctivitis

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