Phlyctenular keratoconjunctivitis is a characteristic
nodular affection occurring as an allergic response
78 Comprehensive OPHTHALMOLOGY
watering. However, usually there is associated
mucopurulent conjunctivitis due to secondary
bacterial infection.
Signs. The phlyctenular conjunctivitis can present in
three forms: simple, necrotizing and miliary.
1. Simple phylctenular conjunctivitis. It is the most
commonly seen variety. It is characterised by the
presence of a typical pinkish white nodule
surrounded by hyperaemia on the bulbar
conjunctiva, usually near the limbus. Most of the
times there is solitary nodule but at times there
may be two nodules (Fig. 4.25). In a few days the
nodule ulcerates at apex which later on gets
epithelised. Rest of the conjunctiva is normal.
2. Necrotizing phlyctenular conjunctivitis is
characterised by the presence of a very large
phlycten with necrosis and ulceration leading to
a severe pustular conjunctivitis.
3. Miliary phlyctenular conjunctivitis is characterised
by the presence of multiple phlyctens
which may be arranged haphazardly or in the
form of a ring around the limbus and may even
form a ring ulcer.
Phlyctenular keratitis. Corneal involvement may
occur secondarily from extension of conjunctival
phlycten; or rarely as a primary disease. It may present
in two forms: the 'ulcerative phlyctenular keratitis' or
'diffuse infiltrative keratitis'.
A. Ulcerative phlyctenular keratitis may occur in
the following three forms:
1. Sacrofulous ulcer is a shallow marginal ulcer
formed due to breakdown of small limbal phlycten.
It differs from the catarrhal ulcer in that there is
no clear space between the ulcer and the limbus
and its long axis is frequently perpendicular to
limbus. Such an ulcer usually clears up without
leaving any opacity.
2. Fascicular ulcer has a prominent parallel leash
of blood vessels (Fig. 4.26). This ulcer usually
remains superficial but leaves behind a bandshaped
superficial opacity after healing.
Fig. 4.25. Phylctenular conjunctivitis.
Fig. 4.26. Fascicular corneal ulcer.
3. Miliary ulcer. In this form multiple small ulcers
are scattered over a portion of or whole of the
B. Diffuse infiltrative phlyctenular keratitis may
appear in the form of central infiltration of cornea
with characteristic rich vascularization from the
periphery, all around the limbus. It may be superficial
or deep.
Clinical course is usually self-limiting and phlycten
disappears in 8-10 days leaving no trace. However,
recurrences are very common.
Differential diagnosis
Phlyctenular conjunctivitis needs to be differentiated
from the episcleritis, scleritis, and conjunctival
foreign body granuloma.
Presence of one or more whitish raised nodules on
the bulbar conjunctiva near the limbus, with
hyperaemia usually of the surrounding conjunctiva,
in a child living in bad hygienic conditions (most of
the times) are the diagnostic features of the
phlyctenular conjunctivitis.
It includes treatment of phlyctenular conjunctivitis
by local therapy, investigations and specific therapy
aimed at eliminating the causative allergen and general
measures to improve the health of the child.
1. Local therapy.
i. Topical steroids, in the form of eye drops or
ointment (dexamethasone or betamethasone)
produce dramatic effect in phlyctenular
ii. Antibiotic drops and ointment should be added
to take care of the associated secondary infection
(mucopurulent conjunctivitis).
iii. Atropine (1%) eye ointment should be applied
once daily when cornea is involved.
2. Specific therapy. Attempts must be made to search
and eradicate the following causative conditions:
i. Tuberculous infection should be excluded by Xrays
chest, Mantoux test, TLC, DLC and ESR. In
case, a tubercular focus is discovered,
antitubercular treatment should be started to
combat the infection.
ii. Septic focus, in the form of tonsillitis, adenoiditis,
or caries teeth, when present should be
adequately treated by systemic antibotics and
necessary surgical measures.
iii. Parasitic infestation should be ruled out by
repeated stool examination and when discovered
should be adequately treated for complete
3. General measures aimed to improve the health of
child are equally important. Attempts should be made
to provide high protein diet supplemented with
vitamins A, C and D.

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