Phlyctenular Keratoconjunctivitis

Question 1

Phlyctenular Keratoconjunctivitis

Answer 1

topical steroid pulse
topical antibiotics vasoconstrictor therapy only oral tetracycline
laboratory testing

Question 2

symptoms/signs

Answer 2

• Most frequently, phlyctenules present secondary to lid disease.
• tearing, irritation, pain, moderate photophobia and may report having similar episodes in the past.
• Phlyctenules (or phlyctens) are focal, translucent lymphocytic nodules generally located at the limbus and usually accompanied by significant inflammation. They present as an elevated, finger-like projection of fibrous tissue across the limbal juncture, onto the peripheral cornea, with overlying pannus (proliferating superficial vessels).
• A conjunctival phlyctenule usually resolves without sequelae, although a limbal phlyctenule may result in localized fibrosis and vascularization of the peripheral cornea. (Less commonly, a corneal phlyctenule can “wander” onto and across the cornea, producing vascularization and scarring.)

Question 3

topical steroid pulse

Answer 3

a. prednisolone acetate (Pred Forte 1%) or prednisolone sodium phosphate (various %’s, phosphate possibly preferred since less penetration of intact cornea, but acetate is stronger clinically); 0.1% fluorometholone acetate (Flarex) or 0.5% loteprednol (Lotemax) sol/gel are excellent alternatives
b. q2h for 3-4 days
c. taper quickly to QID for next 3 days, then D/C
d. use loteprednol (Lotemax, a “soft” steroid) if patient is a steroid responder or
switch to loteprednol if IOP elevates using prednisolone (or continue with prednisolone and add a glaucoma medication to reduce IOP)

Question 4

topical antibiotics

Answer 4

a. use as needed for staphylococcal blepharitis (see Lids Manual)
b. definitely indicated with corneal involvement secondary to blepharoconjunctivitis
c. add a topical antibiotic drop such as Besivance (besifloxacin in Durasite vehicle),
Vigamox, Zymar, (possibly Ciloxan, Polytrim) q2-4h or q4-8h to a single prep steroid such as prednisolone phosphate or flurorometholone acetate (Flarex)
d. fixed antibiotic-steroid combinations
i. Maxitrol (dexamethasone 0.1%/neomycin/polymyxin B)
ii. Pred-G (gentamicin/prednisolone acetate 1%)
iii. Tobradex (tobramycin/dexamethasone 0.10%)
iv. Tobradex ST (tobramycin/dexamethasone 0.05%)
iv. doses should be at steroid frequency (q2h, quick taper QID, D/C)

Question 5

treatment for mild condition

Answer 5

OTC vasoconstrictors and “tincture of time”

Question 6

treatment for resistant staph-caused causes

Answer 6

tetracycline
- tetracycline 250 mg PO, QID, until asymptomatic for 2-3 weeks
- consider reducing daily dose by 250 mg every three weeks (250 mg TID x 3 wks,
BID x 3wks, qD x 3 wks, then D/C)

Question 7

lab testing for TB

Answer 7

a. immigrant populations from Southeast Asia or Central America
b. substance abusers
c. order TB skin test (Mantoux or tine)
d. order chest X ray
e. consult for treatment

Question 8

lab testing for GI parasites

Answer 8

a. serologic testing

b. appropriate therapy (amebicides)

Question 9

mild symptomatic phlyctenule treatment

Answer 9

OTC vasoconstrictor drop QID