Two patients in forty-eight hours with the same unusual eye problem


On the white of the eye, a small bump

Surrounded by vessels so plump

     I don’t know why

     It shows up in the eye,

When the infection is down by the rump.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and seeing patients in Waikari, in New Zealand’s South Island, an hour outside of Christchurch.

Twice in the last forty-eight hours I’ve seen patients with the same unusual eye problem.

Both had irritation of the eye and a little bit of discharge, neither could tell me the color.  When I looked closely at the sclera (the white part of the eye), I saw a white lump the size of a caraway seed, surrounded by inflamed blood vessels. 

“That little lump,” I said in both cases, “Is a phlyctenule.”

I didn’t learn about phlyctenular keratoconjunctivitis(PKC) in med school or residency but in the Indian Health Service, when I took the IHS tuberculosis course.

I have not seen a good explanation of PKC, where an infection somewhere else in the body triggers an allergic reaction in the eye.  In the IHS we maintained a protocol that included a TB skin test and a chest x-ray.

I haven’t seen a case of PKC triggered by TB since I left the Indian Health Service; in the absence of respiratory symptoms or a history of probable exposure I don’t check a chest x-ray.  I ask about other infections, especially skin, and especially fungus.  Usually I don’t get anything to go on and I end up giving the patient an anti-inflammatory eye drop.

Both patients with PKC turned out to have other infections, and in the process of explaining and asking, I uncovered drama, irony and surprising facets of human love.

I don’t see all that many phlyctenules since I no longer work for the Indian Health Service and sometimes I’ll go years without seeing one.  Most docs don’t recognize the abbreviation PKC, but the charge sheet we used in New Mexico listed it on the menu of 50 most common diagnoses.

Outside of contact lenses, most non-traumatic eye problems have to do with infections.  The majority of patients with the red, runny mattering that signals pinkeye have conjunctivitis, mostly viral.  The ones with bacterial infections need antibiotics.  Viruses outside the herpes family clear without treatment; herpes I, herpes II, or the chickenpox/shingles virus in the eye constitute a true eye emergency, requiring a specialist.

Eye infections that keep coming back, I explained to one of the patients, usually respond better to baby shampoo and Q-tips than to antibiotics.  The follicles of the eyelashes become clogged with debris related to the eight-legged crustacean called the human eye mite, and detergent action cuts down on the infestation.

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4 Responses to “Two patients in forty-eight hours with the same unusual eye problem”

  1. Kelley Okuda Says:

    Eye infections usually occur because of improper handling of the eyes. You should avoid touching your eyes with dirty fingers or dirty objects. The eyes are very delicate organs. .`,*’

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    • walkaboutdoc Says:

      Eyes are delicate, and shouldn’t be handled with dirty fingers. On the other PKC has do to with infection outside the eye, though the eye shows the symptoms. Also, clean hands and clean contacts bring on a lot of eye problems if not used gently and properly.

  2. Willy Catozzi Says:

    eye infections can be prevented if you just take care of your eyes by avoiding foreign bodies contacting it. ‘

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  3. Keira Virola Says:

    Many common viral eye infections resolve on their own. In cases of severe viral eye infections, an antiviral eye drop may be prescribed. Some viral eye infections require careful administration of steroid eye drops to reduce related inflammation.`

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