Phlyctenular Keratitis Research Articles

The Features and Treatment Effects on Keratoepitheliopathy for Meibomitis-Related Keratoconjunctivitis.

Meibomitis-related keratoconjunctivitis (MRKC) is characterized by meibomitis with corneal epithelial abnormalities, and can be divided into two types: MRKC accompanied with phlyctenular keratitis, and MRKC accompanied with keratoepitheliopathy that is similar to superficial punctate keratopathy (SPK). The purpose of this retrospective study was to investigate the characteristic features of keratoepitheliopathy and treatment outcomes for MRKC. This study involved 27 eyes of 18 MRKC patients (3 males and 15 females). National Eye Institute (NEI) scores and visual acuity were compared at pre and post treatment. All subjects were treated with a small-dose administration of clarithromycin. Keratoepitheliopathy characteristic to MRKC, yet different in appearance from SPK, was noted in 24 of the 27 eyes. Fluorescein staining revealed granular epithelial lesions generally larger than SPK that coexisted with small dark spots. In 17 eyes, keratoepitheliopathy was located within the pupillary zone, and the visual acuity in 12 eyes was less than 1.0. Our findings showed significant improvement in the NEI score in MRKC (p < 0.0001) and in visual acuity (p = 0.0157) post treatment, and the characteristic features of keratoepitheliopathy in MRKC that are often associated with decreased visual acuity were elucidated. The treatment of clarithromycin was found to be effective for MRKC with keratoepitheliopathy.

Efficacy of azithromycin hydrate ophthalmic solution for treatment of internal hordeolum and meibomitis with or without phlyctenular keratitis.

To evaluate the efficacy of azithromycin hydrate ophthalmic solution for the treatment of internal hordeolum and meibomitis with or without phlyctenular keratitis. Retrospective study. Patients diagnosed with internal hordeolum or meibomitis were prescribed azithromycin hydrate ophthalmic solution twice daily for 2 days and then once daily for 12 days. Depending on the presence of meibomitis-related keratoconjunctivitis (MRKC), we further divided the patients with meibomitis into three subgroups: meibomitis alone (non-MRKC group), meibomitis with non-phlyctenular MRKC (non-phlyctenular group), and meibomitis with phlyctenular MRKC (phlyctenular group). Inflammatory findings (eyelid redness and conjunctival hyperemia) were scored before and after treatment. Some patients also underwent culture testing fluids discharged by the meibomian gland orifices. Three patients (3 eyes) had internal hordeolum and 16 patients (16 eyes) had meibomitis. After treatment, the inflammatory findings disappeared in all eyes with internal hordeolum. Among the patients with meibomitis, three eyes were in the non-MRKC, six in the non-phlyctenular, and seven in the phlyctenular group. The inflammatory findings were significantly improved only in the phlyctenular group. Among seven eyes with positive culture results, Cutibacterium acnes was detected in five, and treatment improved the inflammatory findings in all of these eyes. Azithromycin hydrate ophthalmic solution is effective for the treatment of inflammatory meibomian gland diseases, including internal hordeolum and meibomitis. In particular, the agent is highly efficient in patients with phlyctenular MRKC.

The Therapeutic Effects of a 0.03% Tacrolimus Ointment on Childhood Phlyctenular Keratitis

Purpose: We explored the therapeutic effects of a 0.03% tacrolimus ointment (Protopic) on steroid-resistant phlyctenular keratitis in children. Methods: We enrolled seven eyes of five children with recurrent phlyctenular keratitis despite 3 months of steroid treatment. The topical steroids were tapered and the patients treated with a combination of 0.03% tacrolimus and 0.3% ofloxacin ointment. The logarithm of minimal angle of resolution (logMAR) visual acuity, corneal neovascularization status, and changes in corneal opacity between the baseline and final visit were checked on anterior photographs using Image J software. Results: The average patient age was 6.8 ± 3.0 years (range, 3-9 years) and the treatment duration 8.0 ± 2.0 days (range, 5-10 days). The baseline logMAR visual acuity was 0.42 ± 0.32 and the final value 0.19 ± 0.22. Visual acuity thus improved significantly after treatment (p = 0.026). Corneal neovascularization and phylctenulosis improved in all seven eyes; the fibrotic corneal opacity decreased in two eyes. Conclusions: Topical 0.03% tacrolimus ointment may usefully treat steroid-resistant phlyctenular keratitis of childhood.

Corneal higher-order aberrations in phlyctenular keratitis.

To characterize tomographic patterns and quantify corneal higher-order aberrations (HOAs) in eyes with corneal scar due to phlyctenular keratitis. Retrospective consecutive case series. This study included 51 eyes of 38 patients (24 women; 14 men) with corneal scar due to phlyctenular keratitis. HOAs of the total cornea, and of the anterior and posterior surfaces were measured using anterior segment optical coherence tomography (AS-OCT). Corneal tomographic patterns were classified into five types: increased regular astigmatism, ectasia, asymmetric, flattening and minimal change patterns. The correlation between corneal HOAs and visual acuity was evaluated. Mean months from onset was 50.7 ± 74.7 and mean number of recurrences 2.1 ± 1.1 (1-5). Mean logarithm of the minimal angle of resolution (logMAR) was 0.19 ± 0.31. AS-OCT showed ectasia pattern in 16 eyes (31.4%), asymmetric pattern in 12 eyes (23.5%), increased regular astigmatism pattern in 9 eyes (17.6%), flattening pattern in 3 eyes (5.9%) and minimal change pattern in 11 eyes (21.6%). HOAs of the total cornea were 0.57 ± 0.44μm and 1.16 ± 0.77μm within a 4-mm and 6-mm diameter, significantly larger than in normal controls (P < 0.0001). LogMAR visual acuity was significantly correlated with corneal HOAs (4-mm: r = 0.558, P < 0.0001, 6-mm: r = 0.566, P < 0.0001), central corneal thickness (r = - 0.349, P = 0.016), and corneal astigmatism (r = 0.414, P = 0.004), but not with average keratometric value (r = - 0.092, P = 0.537). The most common tomographic pattern was ectasia, followed by a asymmetric pattern in eyes with phlyctenular keratitis. Corneal HOAs were associated with decreased visual acuity in phlyctenular keratitis patients.

Morphological changes in the meibomian glands of patients with phlyctenular keratitis: a multicenter cross-sectional study.

BackgroundPhlyctenular keratitis is a hypersensitivity reaction of the cornea, and a complication of eyelid margin disease in children and young adults. In this study, we compared the morphology of the meibomian glands in eyelids between phlyctenular keratitis patients and healthy young adults, using noncontact meibography.MethodsThe study included 16 eyes of 13 patients diagnosed with phlyctenular keratitis and 17 eyes of 17 healthy volunteers. Slit-lamp observations of the cornea and eyelid were performed on all subjects. The morphology of the meibomian glands was scored using non-contact meibography (meiboscore). The meiboscore in worse eye was used in bilateral phlyctenular keratitis.ResultsAll eyes with phlyctenular keratitis, but not normal controls, showed corneal nodules, neovascularization, and superficial punctate keratopathy. The mean meiboscore in phlyctenular keratitis patients (upper lid: 2.9 ± 0.3, lower lid: 2.7 ± 0.5) was significantly higher than in controls (upper lid: 0.4 ± 0.6, lower lid: 0.1 ± 0.3).ConclusionsNoncontact meibography enabled visualization of meibomian gland loss in phlyctenular keratitis patients, suggesting a relationship between abnormalities of the meibomian glands in young individuals and the pathogenesis of phlyctenular keratitis.Electronic supplementary materialThe online version of this article (doi:10.1186/s12886-016-0347-5) contains supplementary material, which is available to authorized users.

Role of Azithromycin in the treatment of children meibomian gland disease

AbstractPurpose To determine the usefulness of azitromycin eye drops in the treatment of moderate to severe meibomian gland disease (MGD) in children;Methods Prospective study conducted on 78 children with MGD. At the first examination, all patients already experienced various ophthalmological treatments without any success leading us to test azithromycin eye drops, a macrolide family with anti‐inflammatory properties. The treatment consisted on azithromycin twice a day during 5 days repeated each month for 3 months associated with Dexamethasone eye drops (6 drops a day during one week, the firs month) and daily eyelid hygiene (manual or warm glasses) during the all the treatment course.The follow‐up visits were performed on D7, D30, D60 and D90 with slit lamp examination and photographyResults 78 children were included, 76.4% had severe corneal complications (neovascularization, ulcers, phlyctenular keratitis). After the first week of treatment, a marked improvement in symptoms was observed in all children probably due to the effect of dexametasone drops, At D60; we observed improvement in corneal signs in 76.8% of cases with a significant decrease of corneal neovessels and phlyctenular. Associated with azithromycin eye drops, warm glasses showed a better efficacy than manual technic. In 5 cases, in spite of more than 3 months treatment with azithromycin, the results were no conclusive;Conclusion Azithromycin associated with eyelid hygiene is a very effective in treatment in children with MGD; furthermore, its ease of use, its very good efficacy and the absence of side effects, makes this therapy a good alternative and choice in this disease,

Meibomitis-Related Keratoconjunctivitis

Meibomian gland inflammation, "meibomitis," is associated with ocular surface inflammatory diseases. However, these diseases are poorly defined clinically, making effective treatment difficult. Herein, we propose a new disease subset, termed meibomitis-related keratoconjunctivitis (MRKC). The ocular surface features of MRKC include: meibomitis with redness and swelling of the eyelid margin and palpebral conjunctiva; superficial vascularization and granulomatous nodules in the cornea; and conjunctival hyperemia, similar or identical to that observed in phlyctenular keratitis. The characteristics of MRKC patients include a significantly higher prevalence in women, multiple history of chalazia, close association with meibomitis, the presence of specific human leukocyte antigen association, high Propionibacterium acnes detection rates in meibum culture, and the effectiveness of systemic antimicrobial therapy targeting P. acnes. MRKC may share many clinical features with ocular rosacea, especially during childhood. The clinical effectiveness of systemic antimicrobial agents in treating both diseases suggests the importance of focusing on the elimination of bacteria such as P. acnes.

Spectral domain optical coherence tomography study of pearl-like lesions in the anterior chamber

AimTo study the morphological pattern of pearl-like lesions in the anterior chambers of children before and after management using anterior segment spectral domain optical coherence tomography (SD-OCT).Patients and methodsThis was a prospective, observational cross-sectional study of patients presenting with peculiar pearl-like lesions in the anterior chamber of their eyes. 1 mL of betamethasone sodium phosphate (2 mg/mL) and betamethasone dipropionate (5 mg/mL) was injected subconjunctivally. Follow-ups of all patients were conducted for a period of 6 weeks. Anterior segment imaging was done using SD-OCT and also photo slit lamp before and after management.ResultsTwelve eyes of 12 patients were included in this study. These patients presented with pearl-like lesions in the anterior chamber with signs of anterior uveitis. There was no history of ocular injury or tuberculosis in any patients. Six weeks after subconjunctival steroid injection, all patients achieved mean best-corrected visual acuity, which changed from 0.2 (range 0.1–0.4) to 0.5 (range 0.4–0.8), and the severity of iritis decreased. SD-OCT showed that the lesions at presentation appeared as a globular noncystic mass attached to the back of the cornea, encroaching on the angle of the eye, and attached to the anterior surface of the iris at some points.ConclusionSD-OCT for imaging the anterior segment allowed us to exclude the cystic nature of this pearly lesion. Some similarities may exist between these pearly lesions and superficial phlyctenular keratitis, which may support the immunological and inflammatory origin of these lesions.

The Boston Keratoprosthesis in 2 Patients With Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy

To report the results of Boston keratoprosthesis in patients with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED). Case 1 is a 36-year-old woman with APECED and ocular history of corneal ulcers in both eyes who presented with severe dry eyes. Her ocular examination showed diffuse corneal vascularization and stromal scarring in the left eye. She underwent Boston type 1 keratoprosthesis, cataract extraction, and sulcus intraocular lens implant in the left eye to improve visual acuity. Case 2 is a 49-year-old man with possible APECED and ocular history of phlyctenular keratitis, recurrent corneal erosions, and scarring presented with dense corneal vascularization and scarring in both eyes. He underwent a Boston type 1 keratoprosthesis, clear lens extraction, and posterior chamber intraocular lens implant in the right eye. The surgeries were uneventful. On postoperative day 1, visual acuity of 20/40 was achieved in both patients and it remained stable during the 2-year follow-up period. There were no postoperative complications seen in either patient. APECED is a rare disorder, which can be associated with bilateral keratitis or diffuse corneal vascularization in addition to systemic findings and ectodermal signs. The Boston type 1 keratoprosthesis is a promising treatment option to improve visual acuity in patients with APECED with corneal involvement.

Phlyctenular Keratitis Associated With Meibomitis in Young Patients

To describe the unique clinical features of phlyctenular keratitis, including the association with meibomitis, in young patients. Observational case series. The study population consisted of 23 Japanese patients aged under 35 years with phlyctenular keratitis. We examined their clinical history, signs and symptoms, human leukocyte antigen (HLA), bacterial cultures of meibum, and the efficacy of antibiotics. The minimal diagnostic criteria included corneal nodules consisting of cellular infiltrates and superficial neovascularization. Of the 23 patients, 20 (87%) were women, and 13 (56.5%) had a history of chalazia. In all cases, the lesions and the severity of corneal nodules and neovascularization corresponded well with the location and the severity of meibomitis. The frequency of HLA-A26 and HLA-B35 was significantly increased in our patients (P = .003 and .016, respectively). Propionibacterium acnes in bacterial cultures of pure meibum in 12 of the 20 patients (60%) was statistically more highly positive than those in four of the 17 age-matched normal control subjects (23.5%; P = .028). The characteristics of phlyctenular keratitis in our cases include significantly higher prevalence in female patients, severity variation of ocular surface manifestation corresponding to meibomitis, specific HLA association, and possible P. acnes involvement.

Unusual neutrophil infiltration under the soft contact lens in a patient with Behçet's disease

Background: Behçet's disease (BD) characterized by multisystemic disorders has many kinds of ocular involvement. We report one case of BD with unusual neutrophil infiltration under a soft contact lens (SCL). Case: A 31-year-old woman diagnosed as having BD exhibited bilateral recurrent phlyctenular keratitis and finally developed corneal perforation in the cornea of her right eye. Observations: A therapeutic SCL was immediately fitted on the right cornea as a bandage and another SCL on the left, as prophylaxis. White gelatinous membrane suddenly appeared between the bandage SCL and the cornea in the left eye. After peeling off this gelatinous membrane from the cornea, we examined it after hematoxylin-eosin staining. We also measured the levels of interleukin-8 (IL-8) both in the tears of the patient and on the surface of the SCL. A great amount of neutrophils had infiltrated into this gelatinous membrane. Laboratory data showed a marked increase of IL-8 levels both on the SCL and in the reflex tears (right SCL, 4980 pg/mL; left SCL, 6810 pg/mL. Reflex tears: right, 2080 pg/mL; left, 2170 pg/mL). Conclusion: This case emphasizes the association between the IL-8 level and the disease activity in BD, and provides additional evidence that a BD attack can be induced on the ocular surface under certain conditions.

Corneal lipofuscinosis--clinicopathologic study of 10 patients

Lipofuscin pigments are considered indigestible residues of lysosomal activity associated with aging. We present the clinical and histopathological features of ten patients with corneal lipofuscinosis. Ten patients (five female, five male, mean age 62 years, range 53 to 77 years) underwent penetrating keratoplasty for vascularized corneal scars. The clinical diagnoses were herpes simplex keratitis (5), zoster keratitis (1), phlyctenular keratitis (1), immunologic graft rejection (2) and corneal injury (1). The mean duration of disease was 6.5 years (range 3 to 11 years). On slit lamp examination both linear and diffuse deposits of yellow pigment were noted in the corneal stroma. All corneal buttons were processed for histopathologic and electron microscopic studies. The areas of yellowish pigmentation in the corneal stroma corresponded histopathologically to clusters of macrophages, keratocytes and occasional giant cells containing PAS-positive granules. The granules measured 1 to 3 micrometers and were also present extracellularly. Results of Gram stain were negative, but the material showed vivid autofluorescence. Corneal lipofuscin can be detected at the slit lamp as focal or diffuse yellowish deposits in both the superficial and deep corneal stroma of patients with long-standing keratitis. This is in contrast to corneal iron deposits, which appear as yellowish pigment in the corneal epithelium. The identification of corneal lipofuscin is possible using histochemical and autofluorescent studies. Further studies should address whether corneal lipofuscin predisposes to suture loosening.

Immune reconstitution in keratoconjunctivitis and superficial candidiasis. The role of immunocompetent lymphocyte transfusion and transfer factor.

A 17-year-old white male subject with phlyctenular keratitis, superficial candidiasis, and hypoparathyroidism was found to be anergic in delayed hypersensitivity. Reconstitution of the cell-mediated immune response to Candida albicans by means of allogeneic lymphocyte transfusion and by means of transfer factor, and amphotericin B promptly resulted in the clinical remission of the phlyctenulosis and chronic candidiasis.

Observations on herpetic keratitis and keratoconjunctivitis.

Herpetic keratitis has always been a major problem. In 1936 Gundersen 1 wrote that in New England dendritic keratitis was the most frequent corneal infection recognizable on an etiologic or morphologic basis. In 42 months he found it in 221 patients at the Massachusetts Eye and Ear Infirmary. During the same period there were 97 cases of serpent ulcer, 52 cases of phlyctenular keratitis, and 184 cases of interstitial keratitis. This experience was paralleled in most parts of the United States in the prewar years. During the war the disease was extremely troublesome, constituting, in our experience, the major military corneal problem. Since the war it has become an even more serious source of disability; not only are there relatively more cases but they seem also to have increased in severity and in the frequency with which both eyes become involved. The following analysis of 200 cases of herpetic keratitis

Tuberculous rhinitis: Report of a case

Summary 1. The case of a 12-year-old girl with acute tuberculous nasal disease is described. Phlyctenular keratitis and a primary lung complex were also present. 2. A rapid and satisfactory response to anti-tuberculous chemotherapy was obtained. 3. Thirty-four cases of tuberculous rhinitis over a ten-year period are briefly analysed from records and a trend away from the lupoid towards the acute tuberculous type noted.

CORNEAL TRANSPLANTATION AND PRELIMINARY IRIDECTOMY

T HE technic of corneal transplantation is a well established procedure. Iridectomy as a preliminary operation is here offered and recommended, for the following reasons : (1) It enables the surgeon to estimate the amount of postoperative reaction that may follow in the eye concerned ; (2) it allows for more rapid formation of the anterior chamber; (3) there is less likely to be a prolapse of the iris into the wound after the transplantation. A preliminary iridectomy will enable the surgeon to study the eye involved under operative conditions. This does not apply so rigidly in cases in which an avascular nebulous cornea is present, such as may follow extensive phlyctenular keratitis or a central leukoma resulting from ulcer. But in cases of old interstitial keratitis resulting from syphilis or tuberculosis, in which infiltration is deep and the vascularity potentially marked, it is of value to determine the reaction that may

HERPES CORNEAE

In New England dendritic keratitis appears to be the most frequent corneal infection recognizable on an etiologic or morphologic basis. During the past forty-two months 221 patients with this disease have been observed and treated personally by me. These patients comprise the majority of all those with corneal infection seen during this period in the outpatient department of the Massachusetts Eye and Ear Infirmary. The frequency of dendritic keratitis in comparison with that of other well recognized conditions of the cornea is shown in table 1. Table1.— Incidence of Various Types of Keratitis During Forty-Two Months Total number of new patients in the outpatient department. 41,733 Dendritic keratitis . 221 Interstitial keratitis (syphilitic and nonsyphilitic). 184 Serpent ulcer . 97 Sclerokeratitis. 80 Phlyctenular keratitis . 52 Gonorrheal ulcer (all ages). 27 Disciform keratitis . 18 Trophic or senile marginal ulcers and those attributable to rosacea have been omitted from consideration, since their classification

RESPECTIVE VALUES OF THE VARIOUS FORMS OF TREATMENT OF CERTAIN DISEASES OF THE CORNEA

Phlyctenular keratitis and superficial ulcers of cornea are healed by various remedies, but in many cases with after-presence of nebulae which interfere with acuteness of vision. The various measures used to remove these scars are sometimes satisfactory. When they are not, I have found that use of the combined treatment which I shall describe is often able to clear cornea of these nebulae and give good and even normal vision. My real object in this paper is to call your attention to certain severe types of diseases of cornea, for these are varieties in which respective powers of various healing remedies can be demonstrated. In this class I put deep and spreading ulcers of cornea, calcareous degeneration of cornea, conical cornea, congenital syphilitic keratitis and keratitis profunda. DEEP AND SPREADING ULCER OF THE CORNEA When this ulcer is healed by

CORNEAL LESIONS

My series of cases included the following : phlyctenular keratitis, ten ; serpiginous ulcer, six; vernal catarrh, six; herpes (febrile), six; zoster, two; catarrhal ulcer, four ; superficial marginal keratitis, three ; interstitial keratitis, ten, and ulcerative blepharitis, three. The apparatus used was a small Birch-Hirschfeld Radiation Lamp, made by Zeiss. As the picture shows, it consists of a micro-arc lamp, which is the source of ultraviolet radiations and is mounted on an adjustable stand, a rheostat for use with alternating current, a filter, which transmits rays ranging from 450 to 280 microns, a quartz cell filled with copper sulphate solution for the interception of the heat rays, and at the end of the lamp bar a movable converging lens of quartz. This ultraviolet irradiation has a twofold effect: (1) It is bactericidal, and (2) it has an accelerative influence on the reparative process. The application of the treatment is intensified by the

BRAIN ABSCESS

This case is reported to illustrate the difficulty encountered in the diagnosis of intracranial lesions. There was so little to suggest an abscess that the possibility of it was not considered in reaching a diagnosis. REPORT OF CASE The patient was a boy, aged 11 years, whose family history was free from hereditary diseases. He had been treated at the Mayo Clinic in May, 1917, for phlyctenular keratitis. There was also a history of mumps, chickenpox, and two attacks of measles. He had had no illnesses, accidents, or injuries during the last five years, and very careful questioning failed to reveal a history of a cold, running nose or sore throat during the three months before the onset of the present illness. Jan. 22, 1924, the patient complained of bilateral, frontal headache, to which he had not previously been subject. At first the headaches occurred only on arising in the