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| CASE REPORT |
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| Year : 2021 | Volume
: 33
| Issue : 3 | Page : 333-336 |
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The damaging shield: An incapacitating presentation of vernal keratoconjunctivitis
Mamta Agrawal, Reshma Ramakrishnan, Ayushi Choudhary
Department of Ophthalmology, MGM institute of Medical Sciences, Navi Mumbai, Maharashtra, India
| Date of Submission | 06-Sep-2020 |
| Date of Decision | 23-Sep-2020 |
| Date of Acceptance | 01-Oct-2020 |
| Date of Web Publication | 08-Dec-2021 |
Correspondence Address:
Dr. Mamta Agrawal
Alaknanda Building, D-3/304, Lokgram, Netivali Road, Kalyan East, Thane, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/kjo.kjo_137_20
Vernal keratoconjunctivitis (VKC) is a recurrent, bilateral, seasonal disorder which mostly affects young males. Shield ulcer is an uncommon manifestation of severe form of VKC, seen in 3%–11% of VKC patients, which adversely affects vision. The purpose of this case report is to bring to light that proper timely management can improve visual acuity. A 15-year-old male presented with a complaint of severe itching, with foreign body sensation and redness in BE since 1 week. It was associated with blurring of vision in LE since 2 days. He had history of similar episodes since the past 7 years, usually exacerbating in spring for which he was advised topical steroids and lubricating drops. On examination, RE showed papillae in both upper and lower tarsal conjunctiva. LE showed lid edema, giant cobblestone appearance of papillae in upper and lower tarsal conjunctiva, and a fluorescein stained positive epithelial defect of 3 mm × 4 mm which had elevated plaque containing mucus and debris was noted in the central cornea. He was diagnosed with bilateral VKC with Grade 3 shield ulcer in LE. He was started on topical steroid 4 times and lubricating drops in BE along with topical tacrolimus 0.03% BD in LE. No improvement was noted after 3 days. Margin and base of ulcer with 1 mm of clear margin was scraped and bandage contact lens was put on the 3rd day of starting treatment. On 1 week follow-up of scraping, healing margin was noted with best-corrected visual acuity (BCVA) of 6/60. After 1 month, the BCVA improved to 6/18, and at 3-month follow–up, it improved to 6/9. Shield ulcer, although rare, is an incapacitating vision threatening manifestation of VKC. Timely management of the same is essential to ensure full recovery without any permanent ocular damage. Conservative management should always be considered before surgical treatment in all cases. Various studies are being carried to study the efficacy of immunosuppressive agents especially tacrolimus in treating shield ulcer. Here, we found out that timely instillation of tacrolimus can lead to prompt recovery with significant visual rehabilitation.
Keywords: Giant cobblestone papillae, shield ulcer, vernal keratoconjunctivitis
How to cite this article:
Agrawal M, Ramakrishnan R, Choudhary A. The damaging shield: An incapacitating presentation of vernal keratoconjunctivitis. Kerala J Ophthalmol 2021;33:333-6 |
How to cite this URL:
Agrawal M, Ramakrishnan R, Choudhary A. The damaging shield: An incapacitating presentation of vernal keratoconjunctivitis. Kerala J Ophthalmol [serial online] 2021 [cited 2022 Sep 25];33:333-6. Available from: http://www.kjophthal.com/text.asp?2021/33/3/333/331920 |
| Introduction | |  |
Vernal keratoconjunctivitis (VKC) was first described by Arlt in 1846. VKC is a chronic, recurrent, bilateral conjunctival inflammatory condition which usually affects population with atopy. It is also a seasonal disorder, mostly seen in Mediterranean area, West Africa and Indian subcontinent due to the hot and dry climate. About 45%–75% of patients with VKC have a history of atopy such as asthma, rhinitis, and eczema.[1] It is more common in males in younger population. Onset of the disease is generally before the age of 10 and lasts for 2–10 years. It resolves in late puberty and rarely seen after the age of 20 years. Shield ulcer is an uncommon manifestation of severe form of VKC, seen in 3%–11% of VKC patients. It can be a vision threatening complication of VKC which is divided into three grades by Cameron in 1995 according to its clinical features, treatment, and outcome.[2]
| Case Report | | |
A 15-year-old male presented to ophthalmology outpatient department with complaint of severe itching foreign body sensation and redness in both eyes since 1 week. It was associated with blurring of vision in left eye since 2 days. He had a history of similar episodes since the past 7 years, for which he was advised topical steroids and lubricating drops. His best-corrected visual acuity (BCVA) in RE was 6/6 and in LE was finger counting at 3 m. On ophthalmic examination, RE showed papillae in both upper and lower tarsal conjunctiva and keratinization in upper conjunctiva [Figure 1] and [Figure 2]. LE showed lid edema, giant cobblestone appearance of papillae in upper and lower tarsal conjunctiva. A fluorescein stained positive epithelial defect of 3 mm × 4 mm which had elevated plaque containing mucus and debris was noted in the central cornea in LE [Figure 3]. He was diagnosed with bilateral VKC with Grade 3 shield ulcer in LE. He was then started on topical prednisolone 1% 4 times and lubricating drops in BE along with topical tacrolimus ointment 0.03% BD. No significant improvement was noted after 3 days. He was advised amniotic membrane with debridement. As the patient was unwilling for surgery, conservative management with debridement was tried. Margin and base of ulcer with 1 mm of clear margin was debrided and bandage contact lens was put on the 3rd day of starting treatment [Figure 4]. On 1 week follow-up, healing margin with BCVA of 6/60 was noted [Figure 5]. One month follow-up showed BCVA improving to 6/18 [Figure 6] and at 3 month follow-up, BCVA improved to 6/9 [Figure 7].
| Discussion | | |
VKC is a recurrent, bilateral, seasonal, and atopic disorder. It is an allergic inflammatory condition affecting the tarsus and/or bulbar conjunctiva. It usually presents with severe itching, photophobia, ropy thick mucoid discharge, and foreign body sensation due to giant papillae (cobblestone appearance). It also affects the cornea, showing various manifestations such as Horner-Trantas dots, superficial punctuate keratitis, shield ulcer, corneal plaque, bacterial or fungal keratitis, keratoconus, hydrops, pseudogerontoxon, and corneal opacification. Shield ulcer is a frank corneal epithelial defect caused due to coalesce of punctate epithelial keratitis. It is also known as Togby's ulcer. It does not affect the bowman's layer. It is known to be caused due to two different mechanisms, “mechanical” and “Toxin” hypothesis. Toxin hypothesis suggest that there is corneal epithelium damage due to inflammatory cells, cytokines, and chemokines liberated from T helper type 2 cells. Mechanical hypothesis suggest that giant papillae on the upper tarsal conjunctiva erode the corneal epithelium.[2] This also explains the superior corneal location of the ulcer. It usually has its lower border in half of the visual axis. If it is left untreated, a plaque formation occur containing fibrin and mucus over the epithelial defect causing delayed re-epithelization. Shield ulcers without plaque formation usually have a good visual outcome due to rapid re-epithelialization.[3]
Cameron has classified shield ulcer into three grades: Grade 1-Ulcer with transparent base. They undergo rapid re-epithelization with medical treatment alone. Mild scarring might occur but no other complications. They have good visual outcome.[2] Grade 2-Ulcer with translucent base or ulcer with opaque white or yellow deposits. They undergo delayed re-epithelization and need medical treatment with simple surgical management like scraping. Complications such as bacterial keratitis, amblyopia, strabismus, corneal vascularization, and residual corneal scarring is seen in few patients.[2] Grade 3-Ulcer with elevated plaques above the level of the surrounding epithelium. These ulcers need prolonged treatment and often have to be managed surgically like debridement with amniotic membrane.[2] Avoidance of the allergens is the most important but not feasible treatment. Patients with severe inflammation or shield ulcer are started on topical steroid (fluorometholone 0.1%–0.25% or loteprednol 0.5% or prednisolone acetate 1% or dexamethasone 0.1% ointment) 4–6 times a day, +/- topical antibiotic and cycloplegic agent, cool compresses.[4] Steroids need to be monitored and tapered consciously. Cromolyn sodium, a mast cell stabilizer is also shown to be effective in VKC.[5] Topical calcineurin inhibitors such as cyclosporine A and tacrolimus have also been used.[6] Cyclosporine was noted to cause burning sensation so tacrolimus ointment 0.03% was tried due to its immunomodulatory functions, mainly inhibitory action on the formation of cytokines and release of histamines.[7]
Shield ulcer is a vision threatening complication of VKC and thus needs prompt and vigorous treatment to save the vision. In this case, a Grade 3 ulcer was managed efficiently by simple debridement and topical treatment. Thus, we can say that a trial of conservative management with debridement and bandage contact lens can be undertaken in Grade 3 shield ulcer.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Bonini S, Coassin M, Aronni S, Lambiase A. Vernal keratoconjunctivitis. Eye (Lond) 2004;18:345-51.  |
| 2. | Cameron J. Shield ulcers and plaques of the cornea in vernal keratoconjunctivitis. Ophthalmology 1995:102:985-93. |
| 3. | Kumar S. Combined therapy for vernal shield ulcer. Clin Exp Optom 2008;91:111-4. |
| 4. | Das S. Shield ulcer: A very rare presentation. Kerala J Ophthalmol 2017;29:244. [Full text] |
| 5. | El Hennawi M. Clinical trial with 2% sodium cromoglycate (Opticrom) in vernal keratoconjunctivitis. Br J Ophthalmol 1980;64:483-6. |
| 6. | Takamura E, Uchio E, Ebihara N, Okamoto S, Kumagai N, Shoji J, et al. A prospective, observational, all-prescribed-patients study of cyclosporine 0.1% ophthalmic solution in the treatment of vernal keratoconjunctivitis. Nippon Ganka Gakkai Zasshi 2011;115:508-15. |
| 7. | Samyukta SK, Pawar N, Ravindran M, Allapitchai F, Rengappa R. Monotherapy of topical tacrolimus 0.03% in the treatment of vernal keratoconjunctivitis in the pediatric population. J AAPOS 2019;23:36.e1-0000. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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