Atlas of Ophthalmology

Vernal Keratoconjunctivitis with Shield Ulcer (Colour Photography)

Conjunctiva -> Conjunctivitis, Vernal, Allergic, Chronic
Patient: 13 years of age, male, BCVA 0.3 at OD, 0.8 at OS; Ocular Medical History: symptoms of vernal keratoconjunctivitis since four years. General Medical History: atopic disease since several years, multiple allergies. Main Complaint: photophobia. Purpose: to present vernal keratoconjunctivitis with a shield ulcer. Methods: Colour photography palpebral conjunctiva, colour photography cornea. Findings: Colour Photography palpebral conjunctiva: giant papillary hypertrophy of the upper tarsal conjunctiva Colour Photography cornea: shallow ulcer on the upper part of the cornea with a dense plaque over the ulcer. Discussion: Reddy et al (1) published in 2013 a retrospective, interventional case series. They summarized that vernal keratoconjunctivitis is a chronic bilateral allergic inflammation of the ocular surface with conjunctival hyperemia, chemosis, photophobia, intense itching, pseudoptosis, and filamentous mucous discharge. It is usually seen in young boys in the first decade of their life. Vernal keratoconjunctivitis can present either in the palpebral form or bulbar form (Tranta dots aggregates of epithelial cells and eosinophils) or a mixed form. Complications can be shield ulcer, corneal scarring, dry eye, or limbal stem cell deficiency. Shield ulcer they described as a shallow indolent ulcer usually seen on the upper part of the cornea. Usually it takes months to re-epithelialize. They proposed two hypotheses for the pathogenesis of shield ulcers. The mechanical hypothesis states that the corneal surface is abraded by the giant papilla on the upper tarsal conjunctiva. The toxin hypothesis states that the inflammatory mediators from the eosinophils induce corneal epithelial damage. Initial corneal damage is manifested as coarse punctate epithelial keratopathy, which is converted to corneal ulcers by the mechanical friction of the giant tarsal papillae. A dense plaque is formed over this ulcer by the deposition of toxic eosinophilic granule major basic protein, secreted by activated eosinophils. The deposition is cytotoxic and delays re-epithelialization. They stated that delayed epithelial healing may lead to secondary infections, strabismus, amblyopia, and corneal perforation. Literature: (1) Reddy JC, Basu S, Saboo US, Murthy SI, Vaddavalli PK, Sangwan VS. Management, clinical outcomes, and complications of shield ulcers in vernal keratoconjunctivitis. ) Am J Ophthalmol. 2013 Mar;155(3):550-559.

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