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A 32-year-old white male presented with irritation, foreign body sensation, photophobia
and redness on the temporal area of his conjunctiva that had worsened during the past week.
His ocular history was significant for blepharitis and meibomian gland disease; he reported that both conditions
had persisted for several years.
What is the patient's underlying condition and what signs/symptoms should you look for?
In this case, our patient had phlyctenular keratoconjunctivitis (PKC). PKC is a localized inflammatory or
hypersensitivity disorder that is characterized by the presence of a nodule or "blister." Histologically, these nodules
contain lymphocytes, neutrophils and plasma cells.
The primary cause of PKC is a hypersensitive reaction to an antigen from a bacterial source. Globally, these infections are
often associated with Mycobacterium tuberculosis; however, Staphylococcus aureus is the most common cause
of PKC in the United States.¹
Nevertheless, because of the potential risk for tuberculosis, you should always ask patients with
recurrent corneal PCK about any breathing problems as well as consider ordering a PPD skin test or chest x-ray.
Aggressive treatment with hot compresses, lid cleansers and antibiotic drops or combination drops is warranted to prevent
disease recurrence. More specific treatment strategies for PKC include:
- Steroid drops for two weeks, or combination steroid/antibiotic drops if the patient exhibits significant corneal
involvement of the phlyctenule. Dose the steroids q.i.d. for the first two weeks, followed by a slow taper during the subsequent
two to three weeks.
- 20mg oral doxycycline b.i.d. for one to three months. (Always be sure to rule out tuberculosis in recurrent
corneal cases especially individuals who may have travelled abroad recently).
- Steroid or combination antibiotic/steroid ointment h.s. for one to two weeks in patients with severe symptoms.
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