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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 244-246

Shield ulcer: A very rare presentation


Department of Ophthalmology, Andaman and Nicobar Islands Institution of Medical Science, Port Blair, Andaman and Nicobar Islands, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Sujit Das
Department of Ophthalmology, Andaman and Nicobar Islands Institution of Medical Science, Port Blair, Andaman and Nicobar Islands - 744 104
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_73_17

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  Abstract 


Shield ulcer is a severe form of vernal keratoconjunctivitis (VKC). Shield ulcer is an uncommon, incapacitating corneal manifestation that occurs in 3%–11% of patients suffering from VKC. Patients might present with intense itching, sensitivity to light, and “ropy” discharge from the eyes. Shield ulcer, as a rare complication of VKC, should always be kept in mind for patients suffering from vernal conjunctivitis.

Keywords: Allergic eye disease, shield ulcer, vernal keratoconjunctivitis


How to cite this article:
Das S. Shield ulcer: A very rare presentation. Kerala J Ophthalmol 2017;29:244-6

How to cite this URL:
Das S. Shield ulcer: A very rare presentation. Kerala J Ophthalmol [serial online] 2017 [cited 2018 May 25];29:244-6. Available from: http://www.kjophthal.com/text.asp?2017/29/3/244/224296




  Introduction Top


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.[1] 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. VKC is an allergy associated recurrent inflammatory disease found predominately in prepubescent males. It is characterized by the bilateral presence of palpebral and/or bulbar conjunctiva papillae, corneal keratopathy, and mild to severe itching. The predominant age range is 5–20 years, with a peak incidence at 11–13. Young males are affected twice as often as young females. There is a higher predilection for warm, dry climates as inflammation trends decrease in the cooler months of the year. VKC is self-limiting and typically lasts 4–10 years with remission at puberty. The immune pathogenesis is multifactorial.[2]

Pathogenesis

Classically, it has been thought of as a type I IgE-mediated hypersensitivity reaction. Other studies have demonstrated the involvement of neural factors such as substance P and nerve growth factor in the pathogenesis of VKC, and the overexpression of estrogen and progesterone receptors in the conjunctiva of VKC patients has introduced the possible involvement of sex hormones.[3] Thus, the pathogenesis of VKC is probably multifactorial, with the interaction of the immune, nervous, and endocrine systems. In a previous immunohistochemical study of patients with VKC, we reported that estrogen and progesterone receptors were overexpressed on the conjunctiva by eosinophils and other inflammatory cells. These hormones may bind to conjunctival receptors and exert a proinflammatory effect through the recruitment of eosinophils to the conjunctival tissue.[4]

VKC with severe shield ulcer may represent a very aggressive form of inflammatory disease. The pathogenesis of these ulcers is believed to be mechanical irritation to the corneal epithelium by giant papillae [Figure 1] and [Figure 2] and toxic epitheliopathy from inflammatory mediators secreted by the eosinophils and mast cells.[5]
Figure 1: Shield ulcer with papillary hypertrophy

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Figure 2: Shield ulcer staining positive

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The major symptom is ocular itching. Minor symptoms include photophobia, burning, tearing, mild ptosis, and a thick, ropy, yellow, mucoid discharge. Clinically, there are three forms of conjunctivitis: palpebral, limbal, and mixed. The palpebral form is characterized by polygonal, flat-topped, giant cobblestone papillae of the superior tarsal conjunctiva [Figure 3].[6] The limbal form is less common and marked by a broad, thickened, opacification of the superior limbus. The characteristic Horner-Trantas dots are white dots of eosinophils and epithelial debris. There is corneal involvement in half of cases that range from punctate epithelial keratitis to superficial pannus to corneal shield (Togby's) ulcers. Corneal ulcers are observed in 10% of patients.[6] The diagnosis of VKC is made clinically, based on history and ocular examination. Subconjunctival fibrosis, symblepharon, and conjunctival keratinization can develop.[7]
Figure 3: Papillary hypertrophy

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Complications are visual loss from corneal neovascularization, corneal scars, keratoconus and steroid-induced cataracts, and glaucoma.[6]

Differential diagnoses

  • Atopic keratoconjunctivitis
  • Seasonal allergic conjunctivitis
  • Viral conjunctivitis
  • Giant papillary conjunctivitis (associated with foreign body or chronic inflammation).


Treatment

Preventive: 4 weeks before allergy season begins topical treatment with:

  • Mast cell stabilizer (i.e., cromolyn sodium 4% QID/olopatadine 0.1% BID).


If severe inflammation or shield ulcer is present:

  • 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 [7]
  • Cool compresses.



  Case Report Top


A male patient aged 11 years came to our outpatient department with complaints of watering, mild redness, mild photophobia, and increased blepharospasm in the right eye for the past 15 days. He was taking topical antibiotics and using lubricating eye drops from local hospital. He had similar complaints of itching, watering, and redness for the past 6 months that used to improve on taking topical antiallergic and using lubricating drops. His best-corrected visual acuity was 6/36 improving to 6/24 in the right eye and 6/6 in the left eye. Intraocular pressure was 12 mmHg in both eyes. Slit-lamp examination of both eyes revealed congested conjunctiva, cobblestone appearance of the papillae, and a 3 mm × 2 mm epithelial defect in the paracentral part of the right cornea that stained positive with fluorescein dyes. The ulcer was scrapped and sent for microbiological examination that came negative for culture, potassium hydroxide mount, and Gram stains. Based on the findings, VKC with shield ulcer was made and put on topical fluorometholone (1 drop QID), lubricating drops (1 drop 6 hourly) with topical antibiotics, topical olopatadine, and cycloplegic drugs. Along with that, tablet Vitamin C (500) once daily was given. He was followed every 2 weekly for 3 months. The symptoms and the ulcer got improved subsequently [Figure 4]. The steroid is stopped, olopatadine and lubricating drops continued for more few months.
Figure 4: Six weeks of treatment, ulcer healed

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  Discussion Top


Allergic conjunctivitis, shield ulcer, and VKC are a bilateral, seasonal, and external ocular inflammatory disease of unknown cause.[1] Some of the symptoms of VKC include bilateral giant papillae on the tarsal conjunctiva of the upper eyelids, photophobia, mucous discharge, keratopathy, and itching. Shield ulcer is an uncommon, incapacitating corneal manifestation that occurs in 35%–11% of patients suffering from VKC. Those with VKC frequently have a family or medical history of atopic diseases such as asthma, rhinitis, and eczema.[2] VKC is not a blinding disease, but visual impairment is common if the cornea is involved.[3] Although punctate epitheliopathy is the most common manifestation, shield ulcer with or without plaque, keratoconus, and corneal opacification are not uncommon manifestations of corneal involvement in VKC6.


  Conclusion Top


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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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. 1
    
2.
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. 2
    
3.
Jun J, Bielory L, Raizman MB. Vernal conjunctivitis. Immunol Allergy Clin North Am 2008;28:59-82, vi.  Back to cited text no. 3
    
4.
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. 4
    
5.
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. 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.
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. 811-7  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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