November 2018

CORNEA

Cornea editor’s corner of the world
Finding and identifying a challenging pediatric condition


by Rich Daly EyeWorld Contributing Writer

“If the disease presents in the second decade of life it is more likely to persist into adulthood.
But in cases where it starts early and flares up early, like with 5-year-olds, the disease will burn out by the time they are 10.”
—Asim Ali, MD

In adults, blepharitis and meibomian gland dysfunction are becoming increasingly recognized as major contributory factors in patients with dry eye symptoms. The importance of managing the eyelid margin in these patients is emphasized throughout the Tear Film & Ocular Surface Society DEWS II Report published in 2017. In the pediatric population, however, blepharitis, or what is better described as blepharokeratoconjunctivitis, can be challenging to diagnose and treat. Eyelid findings may be less obvious with predominantly corneal involvement. Treatment often requires topical steroids, which ophthalmologists may be hesitant to initiate. Similarly, oral antibiotics may be required, and the clinician may not be comfortable prescribing them. In children, where the development of amblyopia can occur, it is crucial that this condition be promptly diagnosed and treated. Asim Ali, MD, shares his pearls and experience in treating the many children with blepharokeratoconjunctivitis at the Hospital for Sick Children in Toronto, Canada.

Clara Chan, MD,
Cornea editor


Blepharokerato-conjunctivitis in children is asymptomatic except for a mild red eye, but if left untreated it can progress to corneal scarring with a poor amblyopic prognosis

Ophthalmologists face a challenge with blepharokeratoconjunctivitis, which presents with limited early signs but can have serious long-term outcomes.
The condition involves inflammation of the eyelids and the front of the eye. It occurs in children and adults. Children with blepharokeratoconjunctivitis (BKC) have red eyes and find bright light painful.
“Sometimes there’s an appearance of opacity in the cornea itself and pain,” said Asim Ali, MD, associate professor, Department of Ophthalmology and Vision Sciences, University of Toronto, Canada.
In addition to these typical symptoms, the signs of BKC can include vascularization of the cornea in anterior or posterior BKC.
Dr. Ali’s first-line treatment is topical corticosteroids, depending on the symptoms. He begins with moderate potency and adds topical antibiotics. Among oral therapies, Dr. Ali uses erythromycin, and his initial antibiotic dose period is 3 months.
“If they are bad enough or if there’s significant cornea involvement, I’ll usually tell them that they need to be on it for 3 months at least,” Dr. Ali said. “Three months is the minimum, but I will extend it if there [are] significant issues.”
The natural course of the disease with treatment is that BKC will burn itself out, said Dr. Ali.
“I usually find the earlier the onset, the sooner it is to burn out,” Dr. Ali said. “If the disease presents in the second decade of life it is more likely to persist into adulthood. But in cases where it starts early and flares up early, like with 5-year-olds, the disease will burn out by the time they are 10.”
However, among teenagers, chronic issues are likely to follow.
“They are more like rosacea patients, and this can persist into adulthood with more complications in the long term,” Dr. Ali said.
BKC cases are relatively common, Dr. Ali warned.
“We see them quite often, but there’s no real trend,” Dr. Ali said, adding that there are not usually environmental links.
“It’s not usually associated with an allergy,” Dr. Ali said. “There’s not one environment trigger.”
He has noticed ethnicity-related differences in the occurrence of BKC, however.
“We see children with a Middle Eastern background being the ones who present early, and we see children with more of a European background as the ones who present late,” Dr. Ali said. “This is an observation but not a correlation.”

Editors’ note: Dr. Ali has financial interests with Santen (Osaka, Japan).

Contact information

Ali: asim.ali@sickkids.ca

Finding and identifying a challenging pediatric condition Finding and identifying a challenging pediatric condition
Ophthalmology News - EyeWorld Magazine
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2018-10-30T14:29:51Z
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