Severe Blepharokeratoconjunctivitis Often Causes Corneal Scarring, Astigmatism in Children

Despite its potential to cause irreversible vision loss, blepharokeratoconjunctivitis is often underdiagnosed and misdiagnosed in clinical practice. Efforts to educate eyecare providers on the signs and symptoms of BKC may help improve earlier detection and treatment. Photo: Christine W. Sindt, OD. Click image to enlarge. A frequently overlooked and misdiagnosed cause of ocular inflammation in children is blepharokeratoconjunctivitis (BKC), characterized as a syndrome typically associated with anterior or posterior eyelid margin blepharitis, occurring alongside episodes of conjunctivitis and keratopathy, which may include punctate erosions, phlyctenules, marginal keratitis as well as ulceration and perforation. A new study published in American Journal of Ophthalmology highlighted the importance of timely recognition and treatment of severe BKC due to its potential to cause irreversible ocular morbidity and vision loss. The authors analyzed the clinical characteristics and treatment outcomes of a cohort of pediatric patients with the condition, finding that a notable proportion experienced severe visual complications. Additionally, following discontinuation of treatment, symptom flare-ups were common.The study reviewed diagnostic, imaging and electronic records of 197 patients (315 eyes) aged 18 or younger suffering from severe BKC who were seen at the Hospital for Sick Children in Toronto between 2006 and 2021. All patients had a follow-up of at least six months and displayed one or more severe characteristics of BKC, such as inflammation, new vessel formation, scarring, thinning or lipid deposits affecting the cornea (peripheral and/or central). To ensure consistency in treatment, only cases managed by two experienced pediatric cornea specialists were considered.The mean age at presentation was 7.6 years, with a female predominance of 63%. Roughly two in three patients (65%) had a prior history of chalazion, and 28% had a best-corrected visual acuity worse than 0.3 logMAR, which significantly improved to 17% at the final follow-up. The predominant corneal pathologies noted were corneal scarring (83%) and new vessel formations (49%).The study reported that 142 patients (72%) required systemic antibiotic treatments (azithromycin, clarithromycin, erythromycin or doxycycline), with 23% experiencing flare-ups that necessitated an escalation of therapy, which occurred within one year of stopping treatment in 75% of cases. Notably, 91% of patients achieved a complete response, meaning no disease activity was noted without requiring further steroid or antibiotic treatments, and 15 patients required surgery such as deep anterior lamellar keratoplasty.As the authors relay in their paper, these findings underscore the need for routine screenings for children, particularly those with a history of blepharitis or chalazion. They also highlight the importance of educating eyecare professionals about the symptoms of BKC and the necessity for comprehensive follow-up care, especially in the first year post-treatment when flare-ups are most likely to occur.“We show that this disease can significantly affect visual acuity, lead to central corneal scarring and astigmatism and be asymmetric,” the authors summarized. Therefore, “Early recognition and aggressive management are crucial for preventing complications and improving outcomes.” To control disease activity and minimize flare-ups in pediatric patients with severe BKC, they note that the recommended approach is “combination treatment with systemic and topical antibiotics, along with proper eyelid hygiene and regular follow-up.” Limitations of this study include its relatively small sample size and retrospective nature; thus, future research will be needed to validate and expand upon these findings.Click here for the journal source. Barbara R, Khalili S, Rachdan D, et al. Severe blepharokeratoconjunctivitis in children - the Toronto experience. Am J Ophthalmol. October 19, 2025. [Epub ahead of print]. This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.