Conjunctival & cornea phlyctenule <전안부 conference> Conjunctival & cornea phlyctenule 12999346 서울성모병원 안과 R3 정수경/Ap. 나경선

Case 1. 12999346

C/C conjunctival mass(OD) P/Hx 맹 O 영 M/12 C/C conjunctival mass(OD) P/Hx No systemic disease Ocular trauma/op(-/-) Eyedrops(+) : topical steroid

Ocular exam VA OD 1.0 OS 1.0 IOP OD 25 mmHg OS 20 mmHg EOM straight at 1 position by ACT, no LOM Orbit OU no exophthalmos Lid OU no swelling Conj. OD vessel engorgement, 2 x2.5mm sized yellowish pigmentation OS not injected Cornea OD clear OS clear AC OD deep & cell(-) OS deep & cell(-) Pupil OD round & nl. sized, LR(+) OS round & nl sized, LR(+) Lens OD clear OS clear

Imp. Plan Conjunctival phlyctenule(OD) Steroid responder(OD) Blephasol Autoserem x4/OD O-CS x2/OD

Case 2. 12999346

C/C dec. VA (OD) o/s) 4 yrs ago P/Hx 승 O 비 F/25 C/C dec. VA (OD) o/s) 4 yrs ago P/Hx No systemic disease Allergy(-) Eyedrops/ medication(-) Contact lens use (+)

Ocular exam VA OD 0.1(0.32) OS 0.32(0.8) EOM Straight at 1 position by ACT, no LOM Orbit OU no exophthalmos Lid OU no swelling Conj. OD not injected OS not injected Cornea OD sl. elevated, irregular margin whitish legion c ingrowing vessel (+) OS sl. elevated, irregular margin whitish legion AC OD deep & cell(-) OS deep & cell(-) Pupil OD round & nl. sized, LR(+) OS round & nl sized, LR(+) Lens OD clear OS clear

Imp. Plan Corneal phlyctenule c NV(OD>OS) Blephasol O-LON x4 O-CS x2 O-TMO x1 /OU

3 week later 2 mon later Sx. improved state VA OD/OS 0.8/0.8 Sl. Regressed corneal phylctenule Plan O-LON x 1 Autoserum x4 O-CS x2 /OU

5 mon later BCVA OD/OS 1.0/1.0 IOP OD/OS 12/8 mm Hg at 1:37 pm Conj mild injected c papillary hypertrophy/OU Cornea OD corneal phlyctenule c scar, some SPE (+) OS clear Plan O-LON x1 O-GLU x2 O-CS x2/OU

7 mon later BCVA OD/OS 0.8/1.0 IOP OD/OS 18/12 mmHg at 4:22pm Lid OD sl. Edematous c erythematous OS no swelling Cornea OD new developed NV(+) c subepithelial opacity OS some SPE(+) at inferior area Imp Recurred phylctenule , blepharitis (OD) Plan W-DC 2T O-TMO x1/OU Warm massage O-LVF x4, O-FM x4/OD

9 mon later VA OD/OS 0.63/0.63 Conjunctival injection/OU Imp) Phylectenule recurred(OD) Plan O-LVF x4 O-FM x4 O-HUTF x prn O-SOLC x1 /OD W-DC 2T 지속 솔코린 단백을 제거한 송아지혈액 추출물 조직 재생 작용을 나타냄. 각막궤양, 각막손상, 산 또는 알칼리에 의한 각막부식, 각막 및 결막의 퇴행성 병변, 대수포성 각막염

17mon later Conj. Not injected/OU Cornea OD some subepithelial opacity s NV OS clear Plan RGP 고려 O-CS , O-RFR x prn/OU

Conjunctival & cornea phlyctenule <Review> Conjunctival & cornea phlyctenule 12999346 서울성모병원 안과 R3 정수경/Ap. 나경선

Background A disease of children and young adults Type 4 immune response( delayed hypersensativity) -> infiltration of lymphocyte, macrophage, plasma cells, PMN Etiology Bacteria (S. aureus, N. gonorrhoeae) Mycobateria (Tuberculosis) Virus (HSV) Protozoa Chlamydia Prasites Fungi (Candida) Rasacea dermatitis Tuberculosis가 아이들에게 많이 생길 때, ,,,,,,, phlyctenule이 많이 생김 미국에서는 S. aureus가 많다. 모… 다른 나라에서는Tb가 많다…(특히 Tuberculin test +면 대부분 Tb

Symptoms Tearing Foreign body sensation Photophobia Burning & itching sense Frequent recurrence

Sign Affect any part of the ocular surface, including cornea, limbus, conjunctivae Limbus에서 시작하여 결막 또는 각막으로 진행 Conjunctival phlyctenule 1-2 mm sized raised, amorphous, light pinkish to grayish nodules Ulceration c necrosis : possible Scarring: unusual

Sign Corneal phlyctenule White, raised lesion with surrounding conjunctival injection Clear intervening space(-) between it and the limbus Ulceration, scarring: possible Superficial corneal blood vessel may arise from the limbus multiple, corneal perforation : possible Staphylococcal blepharitis 도 동반 가능함

Diagnostic evaluation Skin testing and chest X-ray for tuberculosis Suspect Chlamydial infection in case of frequent recurrent phlyctenulosis Ulcer(+) -> corneal scraping and culture for bacteria and HSV

Differential diagnosis (1) Salzmann’s corneal nodule 상피하 섬유화, 비진행성 Limbal papillae in VKC 심한 가려움증, 분비물, 결막유두비대 Inflamed pinguecula 3시, 9시 방향, 진행하거나 궤양 일으키지 않음, 결막하 결합조직 의 discoloration 동반 ( tan to yellowish) Salzmann’s corneal nodule May develop from previous ocular inflammatory conditions such as following corneal surgery, interstitial keratitis, trachoma and contact lens wear. Clinical features: Symptoms: usually asymptomatic, but may cause decreased vision if located centrally Signs: Noninflammatory , bm과 epi 사이에 존재 Superficial, elevated multiple bluish-white nodules Located at corneal mid-periphery May increase in number, elevation and size

Differential diagnosis (2) Nodular episcleritis 진행하거나 궤양 일으키지 않음 Infectious corneal ulcer 경계가 불명확, 주로 각막 중심부, AC cell(+) Topical steroid 점안시 더 악화됨 Marginal ulcer Limbus와 병변 사이에 경계가 존재 (clear zone) Staphylococcal marginal keratitisClinical features: Symptoms: irritation, red eye, photophobia nad foreign body sensation. Signs: Peripheral corneal infiltrates and/or ulceration Usually parallel to limbus, separated by a clear corneal zone Presents with marked conjunctival injection Occurs in middle-aged patients but may occur at any age Commonly associated with staphylococcal blepharoconjunctivitis, rosacea or phlyctenulosis Clinical features:

Differential diagnosis (3) Acne rosacea 각막 하부 2/3, superficial vascularization c SPE, infiltration Face나 skin lesion 동반함 Ocular rosacea. Eyelid telangiectasias with inspissated (농축된) meibomian glands. Extensive corneal neovascularization and opacification.

Treatment Determined by the etiology of the phlyctenulosis Principles Corticosteroid Steroid- antibiotic combination Tuberculosis Mild- Astringent Moderate – Topical steroid (O-LON x6, tapering within 1 week) Epidefect(+) – topical antibiotics 먼저 쓸 것

Treatment S. aureus Chlamydia Eyelid hygiene Antibiotic- corticosteroid ointment 2-3회/day for several weeks Oral antibiotics (e.g Tetracycline or erythromycin)- esp. recurred Chlamydia Oral antibiotics – tetracycline * contraindication of TC ; 8세 미만, 임산부 -> Erythromycin 으로 대체함

Treatment Corneal perforation Cyanoacrylate glue PPKP – progress favorable Inflammation이 어느정도 가라 앉은 후 시행 결막 플릭텐은 사실 점안 스테로이드 제제만으로도 치료 가능하다.