PHLYCTENULAR

KERATO-CONJUNCTIVITIS
 Definition
• Phlyctenular kerato-conjunctivitis (PKC) is
characteristic nodular affection occurring
mainly in children as an allergic response
of the corneal and conjunctival epithelium
to endogenous toxin to which the tissue
has become sensitized. Phlycten means
Blister.

October 16, 2006 Dr Sanjay Shrivastava 2

 Epidemiology
• World-wide, sporadic. Most commonly
found in the young in the first and second
decades of life with peak between ages 3
and 15. Usually higher incidence in girls
than in boys. Most commonly found in the
undernourished who live in poor and
overcrowded unhygienic conditions, not
exposed adequately to sunlight. More
common in poorer quarters of the cities,
affecting all races.
October 16, 2006 Dr Sanjay Shrivastava 3
 Etiology
• Phylectenules are an allergic phenomenon, a
reaction of the hypersensitive of epithelium of
the cornea and conjunctiva to any protein; the
reaction is essentially non-specific but in the
majority of clinical cases due to tubercular
proteins.
• Staphylococcus aureus may also act in this way
in highly sensitive patients. May also occur in
patients with metastatic endogenous gonococcal
conjunctivitis.
October 16, 2006 Dr Sanjay Shrivastava 4
 Pathology
• Granulation tissue with fibroblasts and
blood vessels are common in the areas of
epithelial necrosis and ulceration. Lesion
consists of leucocytes into the deeper
layers of the conjunctiva. Central cells are
polymorphs, the peripheral mononuclear
and occasionally giant cells. Neighboring
blood vessels are dilated with proliferation
of their endothelium.
October 16, 2006 Dr Sanjay Shrivastava 5
 Pathology … contd
• Occasionally lesions resolves, but usually
necrosis takes place, the epithelium
sloughs off over the apex of the nodule
and an ulcer forms, the epithelium heals
without leaving any scar.
• An attack does not confer any immunity.

October 16, 2006 Dr Sanjay Shrivastava 6

 Symptoms
• Simple Phlyctenular conjunctivitis has few
symptoms. There is some discomfort and
irritation associated with reflex lacrimation.
In case of secondary bacterial infection,
there is muco-purulent discharge.
Photophobia in cases of corneal
involvement.

October 16, 2006 Dr Sanjay Shrivastava 7

 Signs
• Phlyctenulosis can affect any part of the ocular
surface , including the cornea, limbus and
conjunctiva.
I. Conjunctival Lesions (types)
a. Conjunctival phlyctenules are raised
amorphous , light pinkish to grayish nodules
measuring 1 -2 mm in diameter. Nodule is
usually near limbus but may be anywhere on the
bulbar conjunctiva and rarely affect the palpabral
conjunctiva.

October 16, 2006 Dr Sanjay Shrivastava 8

 Signs ...contd
Congestion is limited around the phlyctens.
After 2 -5 days nodule becomes soft and
ulcerate with necrosis.
b. Pustular Conjunctivitis – large phlycten with
necrosis.
c. Miliary Phlyctenular conjunctivitis –
Phlyctene in large numbers round the limbus.
Secondary infection with frank mucopurulent
conjunctivitis is frequent.
October 16, 2006 Dr Sanjay Shrivastava 9
 Signs … contd.
I. Phlyctenular Keratitis
May develop de-novo or may spread
from the conjunctiva due to anatomic
continuity of epithelium

Types of Corneal Phlyctenular lesions

a. Corneal nodule (Phlycten) – a gray
nodule raised above the surface, a
yellow ulcer forms if epithelium breaks.
October 16, 2006 Dr Sanjay Shrivastava 10
 Signs … contd
Corneal phlyctens usually appear at
the limbus and may migrate either to
cornea or to conjunctiva .
b. When phlycten migrate on to the
cornea, strands of superficial corneal
blood vessels arising from the limbus
follow the course of phlycten.
Superficial vascularized scar is typical
after healing occurs.
October 16, 2006 Dr Sanjay Shrivastava 11
 Signs …contd
The ulcer creeps on the corneal
surface from periphery is called fasicular
ulcer/keratitis.
A typical course of PKC last about two
weeks.
c. Miliary Ulceration – multiple minute
ulcers scattered over a portion of or the
whole of the cornea.
October 16, 2006 Dr Sanjay Shrivastava 12
 Course
• Phlyctenular disease is extremely liable to
relapses

October 16, 2006 Dr Sanjay Shrivastava 13

 Diagnosis
Diagnosis is based on:
a. Clinical picture
b. Skin test for tuberculosis
c. Chest X- ray
d. Reduced resistance may also be
investigated
e. In case of secondary infection – culture
and sensitivity of conjunctival discharge
October 16, 2006 Dr Sanjay Shrivastava 14
 Treatment
• Tuberculous Phlyctenulosis
a. Topical steroid – Prednisolon Acetate
1% six times for 1 week then taper.
b. Steroid + Antibiotic drops (in cases of
secondary bacterial infection)

October 16, 2006 Dr Sanjay Shrivastava 15

 Treatment … contd
• Non-Tuberculous Phlyctenulosis
(Staphylococcus is commonest) –
associated blepharitis and meibomitis
should be treated with oral tetracycline
and Antibiotic steroid ointment or drops for
2 – 3 times for several weeks. In case of
children or pregnant women or nursing
mothers Erythromycin is given in place of
Tetracycline
October 16, 2006 Dr Sanjay Shrivastava 16
 Phlyctenular Keratitis
• In case of Phlyctenular Keratitis broad
spectrum topical antibiotics (Ciprofloxacin,
Ofloxacin, Polymyxin B) are used for
several days before corticosteroid therapy.
• Rare small corneal perforation may be
treated by Cynoacrylate glue. Penetrating
Keratoplasty for Corneal Scar after 6
months of subsidence of inflammation
• Cycloplegics are added
October 16, 2006 Dr Sanjay Shrivastava 17