Chronic Phase
4.19 Staphylococcal Hypersensitivity Staphylococcal Hypersensitivity
Symptoms
Mild photophobia, mild pain, localized red eye, chronic eyelid crusting, foreign body sensation or dryness.
History of recurrent acute episodes, chalazia, or styes.
Signs
(See Figure 4.19.1.)
Critical. Singular or multiple, unilateral or bilateral, peripheral corneal stromal infiltrates with a clear space between the infiltrates and the limbus, and variable staining with fluorescein. Minimal anterior chamber inflammation. Sectoral conjunctival injection, typically.
Other. Blepharitis, inferior SPK, phlyctenule (a wedge-shaped, raised, sterile infiltrate near the limbus, usually in children), peripheral scarring and corneal neovascularization in the contralateral eye or elsewhere in the same eye.
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Differential Diagnosis
z Infectious corneal infiltrates: Often round, painful, and associated with an anterior chamber reaction.
Not usually multiple and recurrent. See 4.11, Bacterial Keratitis.
z Other causes of marginal thinning/infiltrates: See 4.23, Peripheral Corneal Thinning/ Ulceration.
Etiology
Infiltrates are believed to be a noninfectious reaction of the host's antibodies to bacterial antigens in the setting of staphylococcal blepharitis.
Note
Patients with ocular rosacea (e.g., meibomian gland inflammation and telangiectasias of the eyelids) are also susceptible to this condition.
Work-Up
1. History: Recurrent episodes? Contact lens wearer (a risk factor for infection)?
2. Slit-lamp examination with fluorescein staining and IOP check.
3. If an infectious infiltrate is suspected, then corneal scrapings for cultures and smears should be obtained. See Appendix 8, Corneal Culture Procedure.
Treatment Mild
Warm compresses, eyelid hygiene, and a fluoroquinolone antibiotic q.i.d. and bacitracin ophthalmic ointment q.h.s. (see 5.8, Blepharitis/ Meibomianitis).
Moderate to Severe
—Treat as described earlier, but add a low-dose topical steroid (e.g., loteprednol 0.2% to 0.5% or prednisolone 0.25% q.i.d.) with an antibiotic [e.g., trimethoprim/ polymyxin B (Polytrim) or a fluoroquinolone q.i.d.]. Never use steroids without antibiotic coverage. Maintain until the symptoms improve, and then slowly taper.
—If episodes recur despite eyelid hygiene, add systemic tetracycline (250 mg p.o., q.i.d. for 1 to 2 weeks, then b.i.d. for 1 month, and then q.d.) or doxycycline (100 mg p.o., b.i.d., for 2 weeks, and Figure 4.19.1. Staphylococcal hypersensitivity.
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then q.d. for 1 month, and then 50 to 100 mg q.d., titrated as necessary) until the ocular disease is controlled for several months. These medications have an antiinflammatory effect on the sebaceous glands in addition to their antimicrobial action. Topical cyclosporine (e.g. Restasis) b.i.d. may be helpful in controlling eyelid inflammation.
—Low-dose antibiotics (e.g., bacitracin ointment q.h.s.) may have to be maintained indefinitely.
Note
Tetracycline and doxycycline are contraindicated in children <8 years, pregnant women, and breast-feeding mothers. Erythromycin 200 mg p.o., one to two times per day can be used in children to decrease recurrent disease.
Follow-Up
In 2 to 7 days, depending on the clinical picture. IOP is monitored while patients are taking topical steroids.
4.20 Phlyctenulosis Phlyctenulosis Symptoms
Tearing, irritation, pain, mild to severe photophobia. History of similar episodes, styes, or chalazia.
Corneal phlyctenules more symptomatic than conjunctival phlyctenules.
Signs
Critical
z Conjunctival phlyctenule: A small, white nodule on the bulbar conjunctiva, often at limbus, in the center of a hyperemic area.
z Corneal phlyctenule: A small, white nodule, initially at the limbus, with dilated conjunctival blood vessels approaching it. Often associated with epithelial ulceration and central corneal migration, producing wedge-shaped corneal neovascularization and scarring behind the leading edge of the lesion.
Can be bilateral.
Other. Conjunctival injection, blepharitis, corneal scarring.
Differential Diagnosis
z Inflamed pinguecula: Uncommon in children. Located in the palpebral fissure. Connective tissue often seen from lesion to the limbus. Usually bilateral. See 4.9, Pterygium/ Pinguecula.
z Infectious corneal ulcer: With migration, corneal phlyctenules produce a sterile ulcer surrounded by a white infiltrate. When an infectious ulcer is suspected (e.g., increased pain, anterior chamber reaction), appropriate antibiotic treatment and diagnostic smears and cultures are necessary. See Appendix 8, Corneal Culture Procedure.
z Staphylococcal hypersensitivity: Peripheral corneal infiltrates, sometimes with an overlying epithelial defect, usually multiple, often bilateral, with a clear space between the infiltrate and the limbus.
Minimal anterior chamber reaction. See 4.19, Staphylococcal Hypersensitivity.
z Ocular rosacea: Corneal neovascularization with thinning and subepithelial infiltration may develop in an eye with rosacea. See 5.9, Ocular Rosacea.
z Herpes simplex keratitis: May produce corneal neovascularization associated with a stromal infiltrate.
Usually unilateral. See 4.15, Herpes Simplex Virus.
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Etiology
Delayed hypersensitivity reaction usually as a result of one of the following:
z Staphylococcus: Often related to blepharitis. See 4.19, Staphylococcal Hypersensitivity.
z TB, rarely, or another infectious agent (e.g., coccidiomycosis, candidiasis, lymphogranuloma venereum).
Work-Up
1. History: TB or recent infection?
2. Slit-lamp examination: Inspect the eyelid margin for signs of Staphylococcal anterior blepharitis and rosacea.
3. PPD in patients without blepharitis and those at high-risk for TB.
4. Chest radiograph if the PPD is positive or TB is suspected.
Treatment
Indicated for symptomatic patients.
1. Topical steroid (e.g., loteprednol 0.5% or prednisolone acetate 1% q.i.d., depending on severity of symptoms). If there is a lot of tearing, use steroid/antibiotic ointment (e.g., Tobradex) for a short time.
2. Topical antibiotic in presence of corneal ulcer. See 4.11, Bacterial Keratitis.
3. Eyelid hygiene b.i.d. to t.i.d. for blepharitis. See 5.8, Blepharitis/Meibomianitis.
4. Artificial tears (e.g., Refresh Plus or TheraTears) four to six times per day.
5. Bacitracin ointment q.h.s.
6. In severe cases of blepharitis or acne rosacea, use doxycycline 100 mg p.o., q.d. to b.i.d., or erythromycin 200 mg p.o., q.d. to b.i.d. See 5.8, Blepharitis/Meibomianitis.
7. If the PPD or chest radiograph is positive for TB, refer the patient to an internist or infectious disease specialist for management.
Follow-Up
Recheck in several days. Healing occurs usually over a 10- to 14-day period, with residual stromal scar.
When the symptoms have significantly improved, slowly taper the steroid. Maintain the antibiotic ointment and eyelid hygiene indefinitely. Continue oral antibiotics for 6 months. Topical cyclosporine (e.g. Restasis) may be a beneficial steroid-sparing agent in patients with recurrent inflammation.