Corneal Perforation in Phlyctenular Keratitis

PURPOSE: Corneal perforation from phlyctenular keratoconjunctivitis is rarely reported worldwide and no case has been reported in Korea. We report a case of corneal perforation in a patient with phlyctenular keratoconjunctivitis along with a literature review. CASE SUMMARY: A 15-year-old female presented to our clinic with repetitive tears, conjunctival injection, and discomfort in her right eye for several months. Slit-lamp examination revealed oily plugs at the meibomian gland orifices with collarettes, conjunctival injection and a round, whitish elevated lesion accompanying neovascularization of the inferotemporal side of the cornea. As an initial treatment, topical antibiotic was given but no signs of improvement were observed. Hence, topical steroid was applied on suspicion of phlyctenular keratitis and the patient's symptoms and corneal lesion improved. Two months later, the patient's symptoms relapsed and the lesion was found progressing towards the central cornea. The treatment was restarted and the symptoms improved but the corneal lesion continuously progressed towards the center, thinning the central cornea. Seventeen months from the time of initial diagnosis, the patient revisited prior to the scheduled appointment complaining of abrupt tears in her right eye. Slit-lamp examination revealed a corneal perforation at the center of the thinned cornea. Hence, we performed an emergent tectonic corneal patch graft. After the operation, opacity remained covering the visual axis at the central cornea, thus penetrating keratoplasty was performed 10 months later. Henceforth, the patient has remained free of symptoms and visual acuity has been recovered. CONCLUSIONS: Usually phlyctenular keratoconjunctivitis responds well to treatment and does not have a significant influence on vision. However, occasionally phlyctenular keratoconjunctivitis may not respond to treatment and may spread to the central cornea causing loss of visual acuity and even corneal perforation in rare occasions. Therefore, in order to prevent such complications, prompt diagnosis and treatment are essential.

Treatment of Phlyctenular Keratoconjunctivitis with Oral Tetracycline in Recurrent Phlyctenulosis

PURPOSE: We succesfully treated two patients for phlyctenular keratoconjunctivitis which had recurrent episode or was not respond to steroid therapy, with oral tetracycline. METHODS: A 20-year-old girl (Case 1) was referred here because of a two-year history of recurrnet episode of phlyctenular keratoconjunctivitis. There was small pinkish nodule, about 2mm in diameter, and adjacent conjunctival injection in the temporal limbus in her left eye. Corneal opacity and superficial corneal vascularization was located inferiorly. A 12-years-old girl (Case 2) had been followed for 1 years with a recurrent vascularized corneal lesion and infiltration in the right eye. Cultures of the conjunctiva and eyelids were obtained. RESULTS: In case 1, topical steroid treatment led to some improvement but it was only temporarily. She was treated with oral tetracycline at an initial dose of 250mg three times daily for 3 weeks followed by 250mg once daily for 3 weeks. In case 2, doxycycline 100mg twice daily for 2 weeks and tapered 10mg once daily for 3 weeks. All patients experienced rapid relief of symptoms and long term remission of their disease after oral tetracycline or doxycycline treatment. CONCLUSIONS: Oral tetracycline treatment is safe and effective treatment for resistant and recurrent phlyctenular keratoconjunctivitis. In children younger than 10 years of age, doxycycline shluld be recommended alternatively because tetracycline can discolor the teeth.