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Introduction: Phlyctenular keratoconjunctivitis is a nodular affliction characterized by the formation of a small, circumscribed lesion at the corneal limbus and now accepted as a morphologic expression of delayed hypersensitivity to diverse antigens. The condition is one of several corneal disorders that arise as an expression of altered immune mechanisms [4]. Materials and Methods: A 2.5 years old male child presented with a history of watering and redness from his left eye since 3-4 days. On ocular examination, an elevated nodule of approximately 2x1 mm in size with central erosion at 1‘0 clock and of size 1x1 mm was present at 6:0 clock position at the limbus. History of ATT intake in the mother for a period of 6 months, at 1 year of age, was present. Monteux was 25x26 mm (Figure 3), ESR was 34mm in 1st hour, chest radiograph revealed perihilar shadows. Results: Child was put on Antitubercular therapy in the form of rifampicin (10mg/kg/day), isoniazid (10mg/kg/day), pyrazinamide (25mg/kg/day) for 2 months (2HRZ) and isoniazid and rifampicin for another 4 months (4HR). Phlyctens resolved after a follow up of 1 month. Conclusion: Phlyctenular keratoconjunctivitis should be evaluated for tuberculosis and with a positive test, should be referred for tuberculosis therapy.

Purpose To report 2 cases of refractory phlyctenular keratoconjunctivitis treated with topical tacrolimus 0.03% ointment (Protopic). Methods Two white children, aged 5 years and 6 years, respectively, presented with refractory phlyctenular keratoconjunctivitis in 1 eye (left). Both were using corticosteroids and oral erythromycin at presentation with no relief. Examination revealed the presence of catarrhal corneal infiltrates and neovascularization associated with corneal thinning. Topical tacrolimus was added to topical steroids and oral erythromycin twice daily. Results Topical tacrolimus 0.03% ointment was applied into the lower fornix twice a day. In both the patients, improvement in symptoms and signs started within a week of therapy. After 3 weeks of treatment, both patients showed complete resolution of corneal infiltrates and neovascularization. Tacrolimus was successfully tapered in both the patients. There were no side effects. Conclusions Topical tacrolimus 0.03% ointment may be considered in treating severe refractory phlyctenular conjunctivitis.

We present a case of a 33-year-old woman who presented with phlyctenular conjunctivitis while on treatment for spinal intramedullary tuberculosis. She was treated with topical steroids along with continuation of antitubercular therapy, and improved on this treatment.

Posterior uveitis is not a documented feature of Reiter's disease. We describe here a patient of Reiter's disease, who after a bout of dysentery in January 2002 developed macular edema of the right eye with visual acuity of 6/36. In December 2002, she was found to have phlyctenular conjunctivitis. In June 2004, when she reported with scaly plaques over both palms, repeat ophthalmological examination revealed macular degeneration of the right eye. The simultaneous occurrence of Reiter's disease and macular degeneration in this patient may be fortuitous but the immunological basis of both diseases suggests a possible association.

THE PURPOSE of this paper is to call attention to an isolated sign—congestion of the upper quadrant of the bulbar conjunctiva without other ocular involvement. Congestion of the bulbar conjunctiva is a common sign in most diseases of the anterior segment. Congestion only in one sector serves as a guide to a pathological process in the particular sector. Among such typical conditions are phlyctenular conjunctivitis and keratitis, keratitis rosacea, early interstitial keratitis and episcleritis. I have observed a number of patients with congestion of the bulbar conjunctiva localized to the upper quadrant only. The condition did not fit any of the known ocular diseases with sector-like congestion of the bulbar conjunctiva of a local or general cause. Altogether, 20 such patients have been observed, and its incidence is estimated as 1 in 1,500 patients with ophthalmic disease. The age of the affected persons, eight men and 12 women, ranged from

Summary Details of treatment of sixteen cases of phlyctenular conjunctivitis are given. It is important to determine the smallest amount of tuberculin to which the patient will give an intradermal reaction and to start desensitizing injections below this point. If reactions are encountered either locally at the site of injection or at the focus of infection, or generally, with rise of temperature, the amount of tuberculin must be lowered again. In most cases acute inflammation can be overcome in from three to six weeks and sight can be restored, except for an occasional corneal scar.

I. CLINICAL OBSERVATIONS Phlyctenular conjunctivitis is one of the most frequent eye diseases of childhood. Its appearance in typical cases is characteristic. The grayish nodule in or about the cornea, the injection of the surrounding conjunctival vessels, the lacrimation and photophobia present a picture not easily mistaken. The disease is important not only because of the disability which it produces during its active manifestations, but also because the scarring of the cornea which often results in severe or neglected cases produces permanent injury to vision. In spite of numerous investigations into the cause of this conjunctivitis, the etiology has not been definitely determined. Whether the condition is primarily an eye disturbance, or whether it is one of the evidences of constitutional disease, has long been the subject of lively discussion. Moreover, there has been little uniformity of opinion either among those who have contended for its local character or among

Publisher Summary The conjunctiva is divided into bulbar and tarsal portions. The bulbar portion covers the anterior third of the eyeball, and is loosely attached to the sclerotic except at the limbus, where it merges with the corneal epithelium. The tarsal portion is firmly adhered. The nerve supply of the tarsal portion is from the nerves of the lid and that of the bulbar portion is from the ciliary nerves. The function of the conjunctiva is twofold—to moisten the lids; and to assist the lids in the cleansing of the cornea. This chapter presents seven distinct clinical variations of acute conjunctivitis—(1) simple acute conjunctivitis; (2) mucopurulent conjunctivitis; (3) purulent conjunctivitis; (4) ophthalmia neonatorum; (5) membranous conjunctivitis; (6) phlyctenular conjunctivitis; and (7) photophthalmia. It also discusses various syndromes in which chronic conjunctivitis is one of the main symptoms—(1) Parinaud's syndrome; (2) Sjogren's syndrome; and (3) Reiter's syndrome.

Publisher Summary The conjunctiva is divided into bulbar and tarsal portions. The bulbar portion covers the anterior third of the eyeball, and is loosely attached to the sclerotic except at the limbus, where it merges with the corneal epithelium. The tarsal portion is firmly adhered. The nerve supply of the tarsal portion is from the nerves of the lid and that of the bulbar portion is from the ciliary nerves. The function of the conjunctiva is twofold—to moisten the lids; and to assist the lids in the cleansing of the cornea. This chapter presents seven distinct clinical variations of acute conjunctivitis—(1) simple acute conjunctivitis; (2) mucopurulent conjunctivitis; (3) purulent conjunctivitis; (4) ophthalmia neonatorum; (5) membranous conjunctivitis; (6) phlyctenular conjunctivitis; and (7) photophthalmia. It also discusses various syndromes in which chronic conjunctivitis is one of the main symptoms—(1) Parinaud's syndrome; (2) Sjogren's syndrome; and (3) Reiter's syndrome.

In the pediatric and ophthalmologic literature of the past twenty years one finds many references to phlyctenular conjunctivitis. A review of this work shows that although the clinical picture is clearly recognized and varied plans of therapy are suggested, there is still no absolute agreement as to the etiology. In 1925 Aland 1 reviewed the literature on phlyctenular conjunctivitis and came to the conclusion that the preponderance of evidence was in favor of the etiologic role of tuberculosis, but that further statistical and therapeutic study was needed before this relationship could be definitely established. It is our purpose to present as additional evidence of this relationship a study of a group of children with phlyctenular conjunctivitis in whom particular attention was directed to the roentgenologic examination. Two previous investigators have reported the results of roentgenologic examination of patients with phlyctenulosis. Weekers and Colmant 2 obtained roentgenograms of the chests of 50

The complications of paranasal sinus infection in infants and young children are numerous. Acute suppurative paranasal sinus disease and acute suppurative otitis media go together. Numerous ocular conditions, phlyctenular conjunctivitis, iritis, retrobulbar neuritis and choroiditis are usually benefited by the treatment of the coexistent paranasal sinus disease. Dr. McCullough of New York has seen three cases of retrobulbar neuritis secondary to paranasal sinus disease in children under 14 years of age. Dr. White of Boston, recalls several cases of involvement of the optic nerve of children 5 years of age and older. Dr. Gregg of Sioux Falls had a similar case in a child, aged 8 years. There may be an interdependence between chronic multiple infectious arthritis and paranasal sinus disease in infants and young children. The absorption of bacterial protein from an infection of the sinus may be an etiologic factor in the causation of asthma in childhood. In

Phlyctenular conjunctivitis and keratitis (conjunctivitis eczematosis, phlyctenulosis) constitute one of the most frequent ocular maladies of childhood. The dominant characteristics of the disease are, first, its chronicity and, second, its tendency to recurrences. Usually it is not reckoned as a serious ocular malady, either in its clinical course or in its sequelae. An extended experience, however, and a careful analysis of the clinical course and sequelae of phlyctenular trouble neither justify this assumption nor satisfy the conscientious scientist with the results obtained by present methods of treatment. When there is taken into account the suffering experienced by many such patients, the prolonged invalidism they must undergo, the unheralded acute attacks of frequent occurrence which they must accept, the inroads on their visual acuity to which each new attack subjects them, the anxieties of parents as to the outcome of the attacks, the educational loss incident to the patient being compelled

This account deals especially with follicular conjunctivitis, phlyctenular conjunctivitis and keratitis, orbital cellulitis and inflammatory involvement of the deeper tunics of the eye. Cavernous sinus thrombosis is also referred to. Read before the Western Section of the American Laryngological, Rhinological and Otological Society, Colorado Springs, Feb. 26, 1921.

There is some tendency toward reliance on clinical findings for early diagnosis of primary tuberculosis. Practitioners of both pediatrics and general medicine are guilty of this unjustified approach. Many symptoms and symptom complexes have been mentioned. In the Scandanavian countries it has been noted that 95% of the cases of erythema nodosum are associated with tuberculosis. 1 In the United States, however, erythema nodosum occurs much oftener in association with rheumatic fever and occurs infrequently under any conditions. At a recent round-table discussion on tuberculosis conducted by the American Academy of Pediatrics, a group of approximately 35 participants was polled as to the frequency of erythema nodosum. Only one member reported the incidence of as many as two cases each year, and his residence was in northern Michigan, a climate comparable to that of the Scandanavian countries. In the past, presence of phlyctenular conjunctivitis has been considered almost pathognomic of