Chronic non-infective conjunctivitis

1. Phlyctenular conjunctivitis
Definition: Nodular affliction characterized by the formation of a small, circumscribed lesion at the corneal limbus.
Etiology: Hypersensitivity to an endogenous antigen (Type IV hypersensitivity reaction):
1. Tubeculo-protein: The tuberele neverfound in the phlyctenular lesion itself
2. Staphylococcal blepharocon] unctivitis (S. aureus)
3. Intestinal parasites.
4. Septic focus.
Symptoms
1. frritation, discomfort, burning & foreign body sensation.
2. Watery or mucoid discharge. (‘mucopurulent discharge with sticking of the lids may be described if 2ry bacterial infection occurs).
3. Photophobia & blepharospasm in cases with corneal affection.
Signs
1. Phlycten:
• Rounded, raised nodule. 1 -3mm in size.
• Grayish or yellowish.
• Common at the limbus & bulbar conjunctiva & rare on the palpebral conjunctiva.
• Formed of lymphocytic aggregation, covered with intact epithelium. It ulcerates on secondary infection.
• Surrounded by a small area of congestion.
2. Corneal manifestations.
• Corneal phlycten: It may be superficial or under Bowman’s membrane.
• Phlyctenular ulcers:
o Limbal: Single or multiple. May fuse ring ulcer.
o Fascicular: Superficial ulcer, creeping in a serpiginous manner towards the centre & supplied by a leash of Blood vessels. On healing, it leaves maximum opacity where it stops.
• Phlyctenular pannus: Affecting any part of the limbus:
o Thin & vascular with marked irritation.
o Straight vessels, which are deep to Bowman’s membrane.
o Infiltration & vascularization with a rounded edge.
Complications
1. Potentially blinding disease, before advent of steroid therapy.
2. Corneal scarring & visual impairment.
3. Corneal perforation (Very rare).
Differential diagnosis
1. Bulbar spring catarrh        . 4. Acne rosacea.
2. Episcleritis.                        5. Phlyctenular pannus: (From other types of pannus).
3. Inflammed pinguecula.                 
Treatment
1. ttt of the cause of allergy if possible:
• Evaluation & ttt of TB.
• Evaluation of the lid for evidence of chronic staphylococcal infection & Ut.
2. Topical steroids.
3. Local atropine in cases with corneal involvement.
4. Topical astringents.
5. Local antibiotics in cases with secondary infection.
6. Dark glasses.
7. Fascicular ulcer: Cauterized with carbolic acid, then actual cautery for the feeding blood vessels at the limbus.

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