Spark ImagWise 5 – Cornea

Meibomitis – Related Keratoconjunctivitis

Dr. Prabhat Nangia, Dr. Sarang Lambat, Dr. Vinay Nangia 
Suraj Eye Institute, 559 New colony, Nagpur, India

Case Description
A female, 20 years of age, came to us with chief complaints of redness, pain, watering and white opacity in her left eye since two days. She gave a history of previous episodes of redness in both eyes, and chalazion one year back in left eye. On examination, best corrected visual acuity was 6/6, N6 in right eye and 6/9, N6 in left eye.

Slit lamp examination showed macular scar inferiorly in the right cornea (yellow arrow), along with mild bulbar congestion (white arrows) (Fig. 1A). Left eye showed corneal infiltrate inferiorly (yellow arrow), pinpoint opacities at 2,4,8 and 10 0’ clock (white arrows), and 360 degree superficial corneal vascularisation, more prominent inferiorly (Fig. 1B). Fluorescein staining in left eye showed a limbal stem cell deficiency-like picture (white arrows) due to all around superficial vascularisation, and epithelial defect over the infiltrate (yellow arrow) (Fig. 1C).
Careful examination of the lids revealed right eye meibomitis with expression of cheesy meibomian secretions (Fig. 2A) and left eye showed meibomitis (Fig. 2B) with inferior chalazion (Fig. 2C). Examination of the face showed acneiform lesions on her left cheek.

A diagnosis of Meibomitis-related keratoconjunctivitis (MRKC) was made and the patient was advised tablet doxycycline 100 mg BD for two weeks followed by 100 mg OD for one month, azithromycin ointment 1% twice a day over the lid margins for two weeks and carboxymethylcellulose eye drops 0.5% 6 times a day for two months in both eyes. Loteprednol eye drops 4 times a day with weekly taper was advised in left eye after one week. Patient was also advised dermatologist opinion to confirm or rule out rosacea

Ten days later, patient came for review. She was symptomatically better with significant reduction in inflammation and vascularisation of her left cornea. (Fig. 3)

Discussion

Meibomian gland dysfunction or MGD is primarily caused by terminal duct obstruction due to hyperkeratinised duct epithelial cells and increased meibum viscosity. When associated with inflammation of the meibomian glands, it is called meibomitis. 

MRKC is characterised by the presence of meibomitis, redness and swelling of the lid margin and palpebral conjunctiva close to the meibomian orifices, sub epithelial corneal infiltrates, superficial corneal vascularisation and bulbar conjunctival congestion. This tends to occur in young females (age range 3-33 years) with history of multiple chalazia. Cultures of meibum from these patients have been found to grow Propionibacterium acnes, which is also causative for acne vulgaris. While cephalosporins were used topically and systemically by Suzuki et al for MRKC, doxycycline has been shown to have good efficacy against this organism and hence we used oral doxycycline. Topical steroids may also be used in the initial stages to control the inflammatory component.

MRKC should be distinguished from other disorders that may have similar presentation. Phlyctenular keratitis is caused by delayed-type hypersensitivity to proteins produced by M. tuberculosis or Staph. aureus. It also occurs more commonly in females, but at much younger age (mean age of presentation 10.3 years) compared to MRKC (mean age of presentation 18.3 years). Paediatric ocular rosacea may also have similar presentation, but this also presents at much younger age (mean age of presentation 7.9 years) and is associated with dermatological rosacea involving the facial skin and blush region of the head and neck. Oral doxycycline has been used in all these conditions. 

Based on the clinical picture and age presentation, the patient was diagnosed to have MRKC. It has however, also been suggested that all the above conditions may be the same clinical entity as MRKC, given the similar pathogenesis, clinical features and response to antimicrobial agents. Therefore, the possibility that our patient has ocular rosacea or any other similar disorder cannot be ruled out immediately, and the differentials must be kept in mind while examining and treating these patients. 

Readwise

1. Suzuki T. Meibomitis-related keratoconjunctivitis: implications and clinical significance of meibomian gland inflammation. Cornea. 2012 Nov;31 Suppl 1:S41-4.

2. Suzuki T, Teramukai S, Kinoshita S. Meibomian glands and ocular surface inflammation. Ocul Surf. 2015 Apr;13(2):133-49

Correspondence 
Dr Prabhat Nangia
DNB, FICO, FMRF, FAICO
Consultant  
Department of Cornea and Ocular surface
Suraj Eye Institute
Email –education@surajeye.org

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