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    Clinical spectrum of pediatric blepharokeratoconjunctivitis.docx

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    Clinical spectrum of pediatric blepharokeratoconjunctivitis.docx

    Clinical spectrum of pediatric blepharokeratoconjunctivitis Noopur Gupta, MS, DNB, Anuradha Dhawan, MS, FRCS, Sarita Beri, MD, and Pamela Dsouza, MS PURPOSE To uate the incidence, symptoms, clinical signs, and therapy instituted in children with blepharokeratoconjunctivitis BKC. S In this observational, retrospective case series, we reviewed all medical records of pediatric patients presenting to the ophthalmology clinic at the Kalawati Saran Childrens Hospital, New Delhi, India from 2003 to 2006. History, clinical characteristics, and treatment protocol were noted, as well as reason for presentation/referral and subsequent diagnosis. RESULTS Of 5,012 pediatric patients, 615 12 demonstrated features of BKC. Boys were more commonly affected 62 than girls. The mean age at presentation was 6.7 years range, 7 months to 16 years. Lid involvement and conjunctival congestion were consistent fea- tures. Anterior seborrheic variety blepharitis was seen in nearly half the children 302, followed by chalazion 18, external hordeolum 17, ulcerative anterior blepharitis 6, phlyctenular keratoconjunctivitis 6, and marginal ulcerative keratitis 2. Refractive error was evident in 521 of 615 children 85 with BKC. All patients were treated with daily eyelid hygiene, warm compresses, and topical antibiotics. Corticosteroid drops were prescribed in 14 and oral erythromycin in 23. CONCLUSIONS BKC was the commonest diagnosis at consultation among all pediatric referrals. Anterior blepharitis was more common than posterior blepharitis. Severe cases with corneal involve- ment accounted for only 5 of the disease spectrum. J AAPOS 2010;14527-529 B lepharokeratoconjunctivitis BKC is a chronic, in- BKC in an Indian pediatric cohort, 1,3,4 in terms of flammatory eyelid margin disease with secondary conjunctival and corneal involvement. It is a com- mon condition that is often underdiagnosed in children1,2 due to its numerous clinical variants. The clinical spectrum of the disease is varied, with findings ranging from inflamed eyelids, anterior lid margin telangiectasia, accumulations of hard, fibrinous, and crusting scales collarettes around the base of the cilia, and, in severe cases, corneal involvement. BKC has previously been defined as “a syndrome usually associated with anterior or posterior lid margin blepharitis, accompanied by episodes of conjunctivitis, and keratopathy including punctate erosions, punctate keratitis, phlyctenules, marginal keratitis, and ulceration.” 3 Indo-Pakistani and Middle Eastern children have been shown to be more seriously affected by this disease.3 To the best of our knowledge, the present study is the first to uate Author affiliations Department of Ophthalmology, Lady Hardinge Medical College and Associated Kalawati Saran Children Hospital, New Delhi, India The authors have no financial conflicts of interest to disclose. This work was presented at the 17th Annual Meeting of ASIA-ARVO, Hyderabad, January 15-18, 2009. ted February 25, 2010. Revision accepted September 20, 2010. Published online November 22, 2010. Reprint requests Noopur Gupta, MS, DNB, Department of Ophthalmology, Lady Hardinge Medical College and Associated Kalawati Saran Children Hospital, New Delhi, India 110001 email . Copyright 2010 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/36.00 doi10.1016/j.jaapos.2010.09.013 demographics, clinical features, and treatment strategies. Patient and s In this noncomparative, noninterventional, retrospective case series, we reviewed medical records of 5,012 pediatric patients 0-16 years attending the ophthalmology outpatient department of Lady Hardinge Medical College and Associated Kalawati Saran Children Hospital from January 1, 2003 through March 31, 2006, noting the reason for presentation/referral and subsequent diagnosis. The ethnicity of all patients cared for at our hospital was primarily Indian. The study coned to the Declaration of Helsinki and our institutional review board confirmed that its approval was not required for this study. The diagnosis of BKC was based on the presence of the following features tearing, photophobia, recur- rent episodes of red eye, blepharitis recurrent external hordeo- lums or meibomian cysts, and/or keratitis. Morphologically, anterior blepharitis was divided into seborrheic greasy, epithelial squames/flakes at the base of eyelashes and ulcerative pustules, tiny ulcers, and/or hard crusts at the eyelid margin. Children with significant systemic disorders or a history of atopy, vernal keratoconjunctivitis, or perennial allergic conjunctivitis were excluded. Clinical symptoms and signs were graded as mild in case of lid margin disease; moderate if the conjunctiva was also involved; and severe in the case of corneal involvement according to the grading system described previously.3 We further noted the clinical characteristics and treatment strategies in all patients with BKC. Journal of AAPOS 527 Chronic discomfort 615 100 Eye rubbing 522 84.8 Red eye 190 30.9 Watering 246 40 Diminution of vision 231 35.6 Photophobia 44 7.2 528 Gupta et al Volume 14 Number 6 / December 2010 Results A total of 615 children 12.3 were diagnosed with BKC; nearly half of these 47.5 were bilaterally affected. The malefemale ratio was 1.61, with the average age at presen- tation being 6.7 years range, 7 months to 16 years; 109 children with systemic disease or history of atopy/allergy were excluded. The presenting symptoms are given in Table 1; present- ing signs of the disease are delineated in Table 2. On clinical examination, conjunctival hyperemia and lid involvement were consistent features. Anterior blepharitis was more common than posterior blepharitis. Madarosis was seen in 221 children 40 and 2 patients presented with periorbi- tal swelling. Anterior blepharitis squamous was seen in 303 patients 50.7, chalazion in 121 18.2, external hordeolum in 108 17.6, ulcerative anterior blepharitis in 39 6.3, phylctenular keratoconjunctivitis in 34 5.5, and marginal keratitis in 10 1.6. A total of 432 children 70.2 presented with mild BKC 159 children had moderate involvement while 24 children had severe BKC. In 31 cases 5 there was associated corneal involve- ment in the of superficial punctate keratitis, sectoral vascularization, paracentral corneal opacity, marginal ul- ceration, and/or corneal phlyctenule. Of the 615 children, 521 84.7 had refractive error ranging from 0.75 to 4.50 D sphere and 0.25 to 2.25 D cylinder. Systemic tuberculosis was diagnosed based on positive tuberculin skin test and chest roentgeno- gram findings in 10 of the 34 cases with phylctenular kera- toconjunctivitis; acne rosacea was seen in 3 children. Four children had Down syndrome. Microbiological analysis had been carried out in 290 cases and was found to be pos- itive in 52 cases 17.9, with swabs testing positive for Staphylococcus aureus in 34 children, Propionibacterium acnes in 13, and both organisms in 5. Therapies initiated included daily eyelid hygiene, warm compresses, and topical antibi- otic drops and ointment in all cases, steroid drops in 85 cases 13.8, and oral erythromycin in 143 cases 23.2. Discussion This is, to our knowledge, the largest case series of pediat- ric BKC, with previous reports describing cohorts ranging from 8 to 44 patients.1,3-6 BKC is common in India, accounting for 12.3 of all pediatric cases seen in the ophthalmology clinic of our tertiary pediatric hospital. This is similar to the 15 incidence of BKC in the US Table 1. Presenting symptoms of 615 children with blepharokeratoconjunctivitis Symptom Number Table 2. Presenting signs of 615 children with blepharokeratoconjunctivitis Signs Number Conjunctival hyperemia 615 100 Eyelid involvement 615 100 Anterior eyelid inflammation 498 80.9 Posterior blepharitis 451 73.3 Madarosis 221 35.9 Corneal opacity 19 3 Corneal vascularization 19 3 Corneal infiltration 10 1.6 Periorbital swelling 2 0.3 reported by Hammersmith and colleagues.4 The mean age of 6.7 years is also similar to that reported elsewhere.4,5 Jones and colleagues5 reported recurrent chalazia in 18 of their 27 patients 67. They concluded that delayed treatment of BKC in children may result in vision loss from amblyopia.5 Most of the cases of BKC in our study were mild in nature. Corneal involvement was seen in 5 of the cases, which is in contrast to previous studies.3,5 Viswalingam and colleagues3 reported that the most com- mon corneal feature in their 44 Asian and Middle Eastern children was punctate epithelial keratitis and marginal in- filtrates, with frequent marginal corneal ulceration, punc- tate erosions, and corneal phlyctenules. Likewise, Doan and colleagues6 uated pediatric patients in France and concluded that corneal sequelae of BKC are frequent 65 and can be very severe. This could be explained by the fact that Doan and colleagues6 and others4,5 studied a referral population from a specialty cornea clinic, whereas our study included patients presenting to a comprehensive ophthalmic outpatient department of a tertiary level pediatric hospital. Without exception, all patients were treated with a rigor- ous regimen of lid hygiene, hot compresses, and topical antibiotics. Steroid drops were added for 13.8 of patients, while oral erythromycin was used in 23.2. Hammersmith and colleagues4 treated 76 with oral erythromycin n 5 21 or doxycycline n 5 1 and tapered steroids at the initial visit if already prescribed. We found that even when the correct diagnosis was made by the referring ophthalmologists, neither oral anti- biotics nor topical steroids were used in a vast majority of the cases. In contrast, Hammersmith and colleagues4 found that 11 of 29 patients in the US 38 were already being treated with steroids and 4 14 with oral erythro- mycin at presentation. We hypothesize that the reason for less use of steroids in our practice is 2-fold an increasing awareness of its potential side effects, and the fact that bacterial super infection in developing countries remains an important consideration. In conclusion, we concur with the management protocol for pediatric BKC detailed by Wong and Nischal,2 includ- ing eyelid hygiene, warm compresses, and a combination of oral and topical antibiotics, topical steroids, depending on the severity of the disease. Early detection and appropriate Journal of AAPOS Volume 14 Number 6 / December 2010 Gupta et al 529 treatment of this chronic condition is essential to avoid amblyopia and other complications.2,5 Literature Search MEDLINE and EMBASE were searched for the following terms blepharokeratoconjunctivitis, pediatric ocular disorders, clinical features, management of pediatric BKC. References 1. Farpour B, McClellan KA. Diagnosis and management of chronic blepharokeratoconjunctivitis in children. J Pediatr Ophthalmol Strabismus 2001;38207-12. 2. Wong IBY, Nischal KK. Managing a child with an external ocular disease. J AAPOS 2010;1468-77. 3. Viswalingam M, Rauz S, Morlet N, Dart JK. Blepharokeratoconjunc- tivitis in children Diagnosis and treatment. Br J Ophthalmol 2005;89 400-403. 4. Hammersmith KM, Cohen EJ, Blake TD, Laibson PR, Rapuano CJ. Blepharokeratoconjunctivitis in children. Arch Ophthalmol 2005; 1231667-70. 5. Jones SM, Weinstein JM, Cumberland P, Klein N, Nischal KK. Visual outcome and corneal changes in children with chronic blepharokerato- conjunctivitis. Ophthalmology 2007;1142271-80. 6. Doan S, Gabison EE, Nghiem-Buffet S, Abitbol O, Gatinel D, Hoang- Xuan T. Long-term visual outcome of childhood blepharoconjunctivi- tis. Am J Ophthalmol 2007;143528-9. Journal of AAPOS

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