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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 19  |  Issue : 1  |  Page : 74-75

Vernal keratoconjunctivitis with shield ulcer: A rare case report


1 Department of Ophthalmology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
2 Department of Pathology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India

Date of Web Publication17-Dec-2015

Correspondence Address:
Banyameen Iqbal
Department of Pathology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Maharashtra
India
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DOI: 10.4103/1119-0388.172057

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  Abstract 

Shield ulcer is an uncommon, incapacitating corneal manifestation that occurs in 3-11% of patients suffering from vernal keratoconjunctivitis (VKC). Patients might present with intense itching, sensitivity to light, and “ropy” discharge from the eyes. VKC is a bilateral, seasonal, and external ocular inflammatory disease of unknown cause. Those with VKC frequently have a family or medical history of atopic diseases such as asthma, rhinitis, and eczema. We are presenting a case report of a young male patient who presented with complaints of pain, watering, redness, and photophobia. Slit-lamp examination of the patient revealed an epithelial defect in the right eye that upon further examination was diagnosed to be an epithelial ulcer.

Keywords: Allergic conjunctivitis, shield ulcer, vernal keratoconjunctivitis


How to cite this article:
Mushtaq I, Radakrishnan O K, Magdum R, Arun S, Iqbal B, Malhotra J. Vernal keratoconjunctivitis with shield ulcer: A rare case report. Trop J Med Res 2016;19:74-5

How to cite this URL:
Mushtaq I, Radakrishnan O K, Magdum R, Arun S, Iqbal B, Malhotra J. Vernal keratoconjunctivitis with shield ulcer: A rare case report. Trop J Med Res [serial online] 2016 [cited 2019 Nov 15];19:74-5. Available from: http://www.tjmrjournal.org/text.asp?2016/19/1/74/172057


  Introduction Top


Vernal keratoconjunctivitis (VKC) is a bilateral, seasonal, and external ocular inflammatory disease of unknown cause. Some of the symptoms of VKC include bilateral giant papillae on the tarsal conjunctiva of the upper eyelids, photophobia, mucous discharge, keratopathy, and itching.[1],[2] Shield ulcer is an uncommon, incapacitating corneal manifestation that occurs in 3-11% of patients suffering from VKC.[3] They might present with intense itching, sensitivity to light, and “ropy” discharge from the eyes. Those with VKC frequently have a family or medical history of atopic diseases such as asthma, rhinitis, and eczema.[4] We are presenting a rare case of shield ulcer associated with VKC in a young male patient.


  Case Report Top


A young male patient aged 25 years came to the ophthalmology department with complaints of pain, watering, redness, and photophobia in right eye for the last 1 month for which he was taking topical antibiotics and using lubricating eyedrops. He had similar complaints of itching, watering, and redness for the last 6 months that used to improve on taking topical antiallergic and using lubricating medications. His best corrected visual acuity was 6/6 in the left eye and 6/18 in the right eye. Slit-lamp examination of both eyes revealed congested conjunctiva, cobblestone appearance of the papillae [Figure 1], and a 3 mm × 2 mm epithelial defect in the superior part of the cornea covered by a lid that stained positive with fluorescein dyes. The ulcer was scrapped and sent for microbiological examination that came negative for acid-fast bacillus (AFB), fungal, and Gram stains. The inferior part of the ulcer had a clear base while the superior half exhibited inflammatory debris and thick plaque. A diagnosis of bilateral VKC with evolving grade 3 shield ulcer in the left eye was made [Figure 2]. Treatment was started with topical steroid eyedrops, mast cell stabilizers, and lubricating eyedrops. After 2 months of taking medication, the ulcer got healed and visual acuity in the right eye was 6/9.
Figure 1: Everted tarsal conjunctiva with giant papillae

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Figure 2: Shields ulcer in superior part of cornea

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  Discussion Top


VKC is a chronic, seasonally exacerbated allergic inflammation of the ocular surface involving the tarsal and/or the bulbar conjunctiva.[5] VKC is not a blinding disease but visual impairment is common if the cornea is involved. Although punctate epitheliopathy is the commonest manifestation, shield ulcer with or without plaque, keratoconus, and corneal opacification are not uncommon manifestations of corneal involvement in VKC.[6] The pathogenesis of these ulcers is believed to be mechanical irritation to the corneal epithelium by giant papillae and toxic epitheliopathy from inflammatory mediators secreted by the eosinophils and mast cells. Keratic precipitates in shield ulcer of VKC have not been described to date.[7] Shield ulcer is a severe form of VKC. Various cellular adhesion molecules, including intercellular molecular adhesion-1 (ICAM-1), are increased in the conjunctiva of patients with VKC.[8] Proinflammatory cytokines are upregulated in VKC, which augment the expression of ICAM-1 on the corneal endothelial cells.[9] These proinflammatory cytokines enhance the expression of ICAM-1 that bind to the leukocyte function-associated antigen 1 receptor present on all leukocytes and lead to significant leukocyte adhesion on corneal endothelium. VKC with severe shield ulcer may represent a very aggressive form of inflammatory disease. The shield ulcer plaque should always be debrided and keratic precipitates should be looked for on the corneal endothelium. If present, keratic precipitates may further indicate the severity of disease process.[8]


  Conclusion Top


Shield ulcer, as a rare complication of VKC, should always be kept in mind for patients suffering from vernal conjunctivitis.

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.

 
  References Top

1.
Bonini S, Lambiase A, Sgrulletta R, Bonini S. Allergic chronic inflammation of the ocular surface in vernal keratoconjunctivitis. Curr Opin Allergy Clin Immunol 2003;3:381-7.  Back to cited text no. 1
    
2.
Jun J, Bielory L, Raizman MB. Vernal conjunctivitis. Immunol Allergy Clin North Am 2008;28:59-82, vi.  Back to cited text no. 2
    
3.
Bonini S, Bonini S, Lambiase A, Marchi S, Pasqualetti P, Zuccaro O, et al. Vernal keratoconjunctivitis revisited: A case series of 195 patients with long-term followup. Ophthalmology 2000;107:1157-63.  Back to cited text no. 3
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4.
Xu K, Jhanji V. Ophthaproblem. Can you identify this condition? Vernal keratoconjunctivitis with shield ulcers. Can Fam Physician 2012;58:537, 540, 542.  Back to cited text no. 4
    
5.
Barney NP. Vernal and atopic keratoconjunctivitis. In: Krachmer JH, Mannis MJ, Holland EJ, editors. Cornea and External Disease: Clinical Diagnosis and Management. Vol. 2. St Louis: Mosby-Year Book, Inc.; 1997. p. 811-17.  Back to cited text no. 5
    
6.
Iqbal A, Jan S, Babar TF, Khan MD. Corneal complications of vernal catarrh. J Coll Physicians Surg Pak 2003;13:394-7.  Back to cited text no. 6
    
7.
Jain AK, Sukhija J, Chopra I. Keratic precipitates in bilateral vernal corneal ulcer. Asian J Ophthalmol 2006;8:159-60.  Back to cited text no. 7
    
8.
Abu el-Asrar AM, Geboes K, al-Kharashi S, Tabbara KF, Missotten L, Desmet V. Adhesion molecules in vernal keratoconjunctivitis. Br J Ophthalmol 1997;81:1099-106.  Back to cited text no. 8
    
9.
Elner VM, Elner SG, Pavilak MA. Intercellular adhesion molecule-1 in human corneal epithelium. Modulation and function. Am J Pathol 1991;138:525-36.  Back to cited text no. 9
    


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