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 Table of Contents    
Year : 2015  |  Volume : 8  |  Issue : 3  |  Page : 147-150  

Phlyctenular keratoconjunctivitis among children in the tertiary eye hospital of Kathmandu, Nepal

Department of Ophthalmology, BP Koirala Lions Center for Ophthalmic Studies, Institute of Medicine, Maharajgunj Medical Campus, Maharajgunj, Kathmandu, Nepal

Date of Web Publication20-Nov-2015

Correspondence Address:
Gauri Shankar Shrestha
Assistant Professor, BP Koirala Lions Center for Ophthalmic Studies, Institute of Medicine, Maharajgunj Medical Campus, Maharajgunj, Kathmandu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-620X.169884

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Background: This study was conducted to determine clinical profile and etiological factors for phlyctenular keratoconjunctivitis (PKC) in our patients.
Materials and Methods: In the descriptive study, 50 pediatric cases of PKC were enrolled into the study from outpatient department of BP Koirala Lions Center for Ophthalmic Studies between August 2011 and August 2012. The age, sex, exposure to tuberculosis, ocular symptoms, and systemic complaints were recorded. Morphological description of PKC such as number, type, location and scars HISTORY and number of recurrence was also noted. The conjunctival swab was taken from all patients and sent for microbiological examination. Report of systemic involvement, worm infestation was also noted. Mantoux testing for possibility of tuberculosis was also performed.
Results: PKC was detected in 59 eyes of 50 children having mean age of 8.0 ± 6.2 years including 54% males, unilateral involvement in 82%, the limbal involvement in 52% and multiple PKC in 34% children. Associated ocular disorder was blepharitis in 12 (24%) children. Conjunctival swab and culture revealed Staphylococcus infection in 10 (20%) children. Of eight recurrent cases, two had urinary tract infection managed with systemic antibiotics, three had parasitic infestation treated with antihelmentics, one had mantoux positive without having evidence of tuberculosis and two cases had blepharitis as a local factor.
Conclusions: PKC is mostly presented as unilateral disorder of conjunctiva. PKC is associated with blepharitis, Staphylococcus infection, worm infestation and systemic infection.

Keywords: Blepharitis, children, phlyctenular conjunctivitis, Staphylococcus infection, steroid, worm infestation

How to cite this article:
Gautam P, Shrestha GS, Sharma AK. Phlyctenular keratoconjunctivitis among children in the tertiary eye hospital of Kathmandu, Nepal. Oman J Ophthalmol 2015;8:147-50

How to cite this URL:
Gautam P, Shrestha GS, Sharma AK. Phlyctenular keratoconjunctivitis among children in the tertiary eye hospital of Kathmandu, Nepal. Oman J Ophthalmol [serial online] 2015 [cited 2023 Mar 26];8:147-50. Available from: https://www.ojoonline.org/text.asp?2015/8/3/147/169884

   Introduction Top

Phlyctenular keratoconjunctivitis (PKC) is a nodular affliction characterized by the formation of a small circumscribed lesions at the corneal limbus that represents an allergic cell-mediated response within the conjunctiva and/or cornea to some antigen.[1] It was thought that the main antigen responsible for PKC was tuberculoprotein.[2] However, the other sensitizing antigens were also reported in literatures such as staphylococcal products,[3] worm infestation,[4],[5] fungi, viruses,[6] and parasites.[7] PKC is alternatively named as childhood ocular rosacea, as the ocular findings are similar to those seen in adults with acne rosacea. However, this latter skin condition is very rare in children.[8] In many cases, some nutritional or vitamin deficiencies were also reported to be associates with PKC as contributing factor of delay recovery.[9],[10] Though, the exact mechanism of the production of the phlyctenule is still uncertain, PKC is accepted as a morphologic expression delayed hypersensitivity to various antigens. In many instances, one is not able to point out a single etiological factor.[9] The disease occurs typically in acute, self-limited and the lesion may resemble a blister at one stage, but the small red nodule of lymphoid tissue characteristically develops into a microabscess that ulcerates and heals in 10–14 days.[11] PKC develop first and most prominently at the limbus although later they may spread over the bulbar conjunctiva and cornea. Rarely, they have been seen on the palpebral conjunctiva. Although PKC occasionally resolves spontaneously, it usually necroses with a sloughing of the epithelium over its apex.[12] We examine many cases of PKC in our clinic. This study was conducted to determine clinical profile and etiological factors for PKC in our clinical patients.

   Materials and Methods Top

In the descriptive study, 50 pediatric cases of PKC were enrolled into the study from Out-patients Department of B. P. Koirala Lions Center for Ophthalmic Studies between August 2011 and August 2012. This study was approved by Institutional review board of Institute of Medicine and adhered to the principles outlined in the Declaration of Helsinki.

The age, sex, exposure to tuberculosis, ocular symptoms and systemic complaints were recorded. Presenting and best corrected visual acuity was noted on the Snellen's chart among school aged children and on the Kay-Picture chart or the Sheridan-Gardiner chart among preschool children. Central Steady method (CSM) was used for the children aged below 2 years to record the visual status.

Slit Lamp Biomicroscopy was performed on each child to assess morphological description of PKC such as number, type, location and scars History and number of recurrence was also noted. Careful examination of lids, conjunctiva and cornea was performed to find out associated ocular surface disorders. The conjunctival swab was taken from all patients and sent for microbiological examination.

Report of systemic involvement such as upper respiratory tract infection (URTI), Urinary tract infection (UTI), worm infestation and Tuberculosis were received by reviewing a report of pediatrician and laboratory investigations such as report of urine routine for pus cells, urine culture and sensitivity for organism isolation, stool examination for cysts and ova, chest X-ray for pulmonary lesions, Mantoux test for TB allergy, CBC, DLC and ESR for infections. Patients considered to have definite evidence of TB disease were those with characteristic pulmonary lesions on X-ray, or those already on antitubercular treatment. Ulceration on Mantoux testing or induration ≥15 mm was taken to indicate TB allergy. Patients with at least one out of three stool examinations positive for worm cysts or ova were taken to have worm infestation. Patients with clinical evidence of lid margin or conjunctival infection, confirmed microbiologically, were taken to have infective blepharitis or conjunctivitis.

Regardless of etiological association, all cases were prescribed topical steroid flourometholone 1% QID for a week with tapering does. In recurrence and multiple PKC cases, dexamethasone 0.01% along with antibiotic topical tobramycin 0.3% was prescribed and reviewed the cases in follow up and average date of resolution was noted. Ma­jority of the cases were followed up to 2-3 weeks.

   Results Top

Among 50 patients, 27 (54%) males and 23 (46%) females having mean age of 8.0 ± 6.2 years (range 6 months–15 years). Detailed description of PKC is presented in [Table 1]. Majority of cases were unilateral (82%). PKC was almost equally manifested in the limbus [Figure 1] and [Figure 2] and conjunctiva [Figure 3]. Corneal PKC was not noted. Multiple PKC [Figure 4] was present in 34% children. PKC was present in both nasal and temporal sides in 6 children (12%). Associated ocular disorders were present in 16 (32%) children comprising of blepharitis in 12 (24%) children and vernal keratoconjunctivitis in 4 (8%) children. Conjunctival swab and culture revealed Staphylococcus infection in 10 (20%) children; they were all having blepharitis (83.3%).
Table 1: Detail Description of Phlyctenular Keratoconjunctivitis

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Figure 1: Limbal phlyctenule

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Figure 2: Limbal phlyctenule with fluorescein staining

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Figure 3: Conjunctival phlyctenulosis

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Figure 4: Multiple limbal phlyctenule

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Systemic association was present in 8 (16%) children (three cases of upper respiratory tract infection (URTI), two cases of urinary tract infection (UTI), three cases of worm infestation). Three cases of URTI and two cases of UTI received systemic antibiotic therapy from pediatrician. Three cases with worm infestations received tablet albendazole 400 mg stat.

Complete resolution of PKC was present in 42 (84%) children with topical steroid and antibiotic treatment. Duration of treatment varied from 5–14 days. None of the cases had cervical adenitis. However, 8 (16%) children suffered a recurrent PKC. Among the recurrent cases, two cases with UTI (25%), three cases with worm infestations (37.5%), one case with mantoux positive (12.5%) and two cases of blepharitis (25%). A mantoux positive case is one who had induration was equal to 21 mm (standard ≥15 mm). However, this child had normal X-ray report. The recurrent cases having blepharitis was infective. The recurrent cases resolved in 2–3 weeks.

   Discussion Top

Childhood PKC is often a misdiagnosed condition (Thygeson P. 1951). PKC is seen in first two decades of life.[6] In this study, mean age of presentation was 8.0 ± 6.2 years. Male to female ratio in the study was 1.17. In a study by Livia et al., the mean age at presentation was 10.2 years having female preponderance (80.4%).[13] In that study, all the patients had lid and corneal changes and 34 (66.7%) patients had conjunctival changes. This is unlike our study where majority of cases had no lid or corneal changes. This finding is also similar to the Culbertson et al. study where corneal thinning and perforation were rare complications of the disease.[3] A strong female preponderance was also reported in the literatures.[6],[14] The reason for discrepancy in female preponderance in our study could be due to the fact that male children are brought to hospital more frequently than girl children.

Ten (20%) children had culture positive conjunctival swabs. Nine of them had Staphylococcus aureus and one had S.aureus and Staphylococcus epidermidis growth positive. In the Viswalingam et al. study 15 (34.1%) children had culture positive lid margin and conjunctival swabs. Of these, 12 had growth of Staphylococcus aureus, one had S. epidermidis, and two had mixed S aureus/S epidermidis. In their study, they had conjuctival phlecten in nine cases and corneal phlecten in two cases out of 44 cases of blepharoconjuctivitis.[14] In our study, conjuctival phlecten was seen in 24 (48%) subjects and limbal phlecten was seen in 26 (52%) cases of PKC. Limbal phlycten is the most common and most frequently manifested PKC reported in the literature.[1],[6]

Association of phlyctenular keratoconjuctivitis with hypersensitivity to tuberculoprotein even without tubercular disease can be found.[1],[6] In a study conducted by Rohatgi and Dhaliwal in 86 patients (76.7%), phlyctenular eye disease was associated with tuberculosis.[2] However in our study no direct evidence of tubercular etiology was found.

Thygeson and Stone believes that PKC is always due to bacterial allergy and never is a result of nonbacterial proteins, e.g,. hayfever, urticaria.[10] He has never observed development of phlyctenulosis in vernal catarrh or in simple allergic conjunctivitis. However in our study, vernal keratoconjuctivitis was seen in four cases (8%), UTI in two cases (4%), and URTI in three cases (6%).

PKC was also reported to be associated with acne rosacea.[3],[15],[16] However in our study, PKC was not found in acne rosacea. This could be because our follow-up period was the least compared to the other studies and most of our patient did not followed up once the phlycten resolved. The Oltz and Check study reported that ocular manifestations can occur in up to 50% of patients with rosacea and may precede dermatologic manifestations in 20%.[17]

Topical corticosteroids are considered to be the best option for PKC, but steroid dependency is frequent especially in recurrent cases. In the Doan et al. study topical Cyclosporin A 2% has been advocated as an effective treatment for children with PKC associated with severe corneal inflammation.[18] In the Culbertson et al. study, oral tetracycline or erythromycin treatment was noted to produce long-lasting remission of PKC in affected children.[3] However in our cases, a short course of flourometholone 1% was proved to be enough to resolve PKC in duration of a week. This could be because the numbers of recurrent cases were less (8 out of 50) and most of them presented early to us.

In the literatures, PKC was seen as a part of spectrum of manifestation of blepharokeratoconjunctivitis (BKC) in children.[14],[18],[19] Since the numbers of patient enrollment were less in our study, the wider perspective of BKC was missed.

   Conclusions Top

PKC is mostly presented as unilateral disorder of conjunctiva. Associated ocular condition in PKC is blepharitis. Possibility of Staphylococcus infection should not be undermined. In recurrent cases, systemic as well as local cause should be identified so as to prevent further relapse and ocular morbidity. PKC resolves easily with combination of topical steroid an antibiotic therapy.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Sorsby A. The aetiology of phlyctenular ophthalmia. Br J Ophthalmol 1942;26:159-79.  Back to cited text no. 1
Rohatgi J, Dhaliwal U. Phlyctenular eye disease: A reappraisal. Jpn J Ophthalmol 2000;44:146-50.  Back to cited text no. 2
Culbertson WW, Huang AJ, Mandelbaum SH, Pflugfelder SC, Boozalis GT, Miller D. Effective treatment of phlyctenular keratoconjunctivitis with oral tetracycline. Ophthalmology 1993;100:1358-66.  Back to cited text no. 3
Jeffrey MP. Ocular diseases caused by nematodes. Am J Ophthalmol 1995;40:41-52.  Back to cited text no. 4
Hussein AA, Nasr ME. The role of parasitic infection in the aetiology of phlyctenular eye disease. J Egypt Soc Parasitol 1991;21:865-8.  Back to cited text no. 5
Thygeson P. The etiology and treatment of phlyctenular keratoconjunctivitis. Am J Ophthalmol 1951;34:1217-36.  Back to cited text no. 6
Al-Hussaini MK, Khalifa R, Al-Ansary AT, Hussain GH, Moustafa KM. Phlyctenular eye disease in association with Hymenolepis nana in Egypt. Br J Ophthalmol 1979;63:627-31.  Back to cited text no. 7
Erzurum SA, Feder RS, Greenwald MJ. Acne rosacea with keratitis in childhood. Arch Ophthalmol 1993;111:228-30.  Back to cited text no. 8
Gokhale AM, Limaye SR. Etiology of phlyctenulosis. Indian J Ophthalmol 1965;13:65-7.  Back to cited text no. 9
  Medknow Journal  
Thygeson P, Stone W. Epidemiology of inclusion conjunctivitis. Arch Ophthalmol 1942;27:91-122.  Back to cited text no. 10
Udell IR, Weyne JS. Phlyctenular Keratoconjunctivitis. Vol. 4, Ch. 8. Available from: http://www.eyecalcs.com/DWAN/pages/v4/v4c008.html. [Last accessed on 2014 Aug 22].  Back to cited text no. 11
Thygeson P, Diaz-Bonnet V, Okumoto M. Phlyctenulosis. Attempts to produce an experimental model with BCG. Invest Ophthalmol 1962;1:262-6.  Back to cited text no. 12
Teo L, Mehta JS, Htoon HM, Tan DT. Severity of pediatric blepharokeratoconjunctivitis in Asian eyes. Am J Ophthalmol 2012;153:564-70.e1.  Back to cited text no. 13
Viswalingam M, Rauz S, Morlet N, Dart JK. Blepharokeratoconjunctivitis in children: Diagnosis and treatment. Br J Ophthalmol 2005;89:400-3.  Back to cited text no. 14
Farpour B, McClellan KA. Diagnosis and management of chronic blepharokeratoconjunctivitis in children. J Pediatr Ophthalmol Strabismus 2001;38:207-12.  Back to cited text no. 15
Hong E, Fischer G. Childhood ocular rosacea: Considerations for diagnosis and treatment. Australas J Dermatol 2009;50:272-5.  Back to cited text no. 16
Oltz M, Check J. Rosacea and its ocular manifestations. Optometry 2011;82:92-103.  Back to cited text no. 17
Doan S, Gabison E, Gatinel D, Duong MH, Abitbol O, Hoang-Xuan T. Topical cyclosporine A in severe steroid-dependent childhood phlyctenular keratoconjunctivitis. Am J Ophthalmol 2006;141:62-66.  Back to cited text no. 18
Gupta N, Dhawan A, Beri S, D'souza P. Clinical spectrum of pediatric blepharokeratoconjunctivitis. J AAPOS 2010;14:527-9.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]

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