Severe Blepharokeratoconjunctivitis in Children—The Toronto Experience

Abstract

PurposeTo report on the clinical characteristics and treatment outcomes of a large cohort of pediatric patients who presented with severe blepharokeratoconjunctivitis (BKC). DesignRetrospective consecutive cohort study. SubjectsPatients aged under 18 years with BKC presented to the Cornea Service at the Hospital for Sick Children, Toronto, Canada, between 2006 and 2021. MethodsChildren with severe BKC, defined as BKC with inflammation, new vessel formation, scarring, thinning, and lipid deposits affecting the peripheral and/or central cornea, and a follow-up of at least 6 months were included. Basic demographics, best corrected visual acuity (BCVA), refractive error, disease laterality, type and duration of antibiotic therapy, flare-up rate, and extent of corneal involvement were analyzed. Main Outcome MeasuresBCVA, refraction, extent of corneal involvement, procedures, flare-up of BKC, and time to flare-up rate after cessation of systemic antibiotics treatment. ResultsOut of 2542 patients with blepharitis, 197 patients (315 eyes) were identified with severe BKC. The mean age at the first presentation was 7.6 years, with a 2:1 female predominance. At the presentation, 65% had a history of chalazion, and 28% had BCVA worse than 0.3 logMAR, which improved to 17% at final follow-up (P = .007). The most striking corneal pathologies affecting the peripheral and central cornea were scarring (83%) and new vessel formation (49%). One hundred forty-two patients (72%) required systemic antibiotics (azithromycin, clarithromycin, erythromycin, or doxycycline), of whom 23% experienced flare-ups requiring an escalation in treatment with topical steroids and/or systemic antibiotics, and 75% of these occurred within the first year of treatment cessation. Ninety-one percent of patients achieved complete response, defined as no disease activity and no use of topical steroids or systemic antibiotic treatment. Fifteen patients required surgical intervention. ConclusionsBKC is a serious disease in children, potentially causing irreversible ocular morbidity and vision loss. Central scarring and astigmatism can affect vision in a significant proportion of children. Therefore, early identification and treatment are necessary to reduce disease morbidity. Close follow-up is crucial as one in four patients may experience a flare-up, especially within the first year of treatment cessation. Most patients with severe BKC require both topical steroids and systemic antibiotics to control disease activity.