Kerala Journal of Ophthalmology

: 2020  |  Volume : 32  |  Issue : 3  |  Page : 232--233

Pigment sign in vernal keratoconjunctivitis

Amanda Mohanan-Earatt, Sanjeev Srinivas 
 Cornea Services, Darshan Eye Care, Chennai, Tamil Nadu, India

Correspondence Address:
Dr. Amanda Mohanan-Earatt
Darshan Eye Care, Anna Nagar, Chennai - 600 040, Tamil Nadu

How to cite this article:
Mohanan-Earatt A, Srinivas S. Pigment sign in vernal keratoconjunctivitis.Kerala J Ophthalmol 2020;32:232-233

How to cite this URL:
Mohanan-Earatt A, Srinivas S. Pigment sign in vernal keratoconjunctivitis. Kerala J Ophthalmol [serial online] 2020 [cited 2021 Apr 21 ];32:232-233
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Full Text

 Clinical Sign-Pigment Sign in Vernal Keratoconjunctivitis

Multiple fine, granular, discrete, dot-like brown pigments are seen in the perilimbal bulbar conjunctiva of children and young adults diagnosed with vernal keratoconjunctivitis (VKC) [Figure 1] and [Figure 2].[1]{Figure 1}{Figure 2}

 Seen In

Vernal Keratoconjunctivitis.

 Described By

Rao and Padmanabhan in 2002.[1]

 Cardinal Features

Multiple faint to dark brown, discrete, fine pigments are seen scattered in the perilimbal bulbar conjunctiva of at least one eye.[1]

The most common site of pigmentation is the interpalpebral conjunctiva followed by the inferior and superior bulbar conjunctiva.[2]

Pigmentation is noted to occur in all grades of VKC. However, it is of greater clinical importance in the diagnosis of mild or quiescent forms of the disease when palpebral and limbal changes are not very characteristic.[2]

There is no relationship of density of pigmentation with age, severity, or chronicity of the disease. The pigmentation persists even when the disease is in remission.[3]

 Why it Occurs?

It is hypothesized to be the result of complex cellular immunity interactions occurring on the ocular surface, with the limbus serving as the seat of antigen–immune system interaction. The pigmentation may be representative of the afferent activity occurring, due to the transportation of foreign antigens to regional lymph nodes, by the Langerhans cells in a milieu of mast cells and melanocytes.[2]

 What Else to Examine?

Other signs/associations of vernal keratoconjunctivitis

Tarsal papillae, cobblestone papillae, limbal nodules, Horner–Trantas dots, pseudogerontoxon, superficial punctate keratitis, corneal erosion, epithelial defect, plaque formation, shield ulcerExamine for corneal ectasia, cataract, and glaucoma.[4]

Differential diagnosis and signs to exclude them

Vitamin A deficiency may show perilimbal pigmentation, which can be differentiated from VKC by the presence of Bitot's spots and the absence of other limbal and palpebral changes[3]In chemical injury, pigmentation of the bulbar conjunctiva may be seen. Apart from the history of trauma and associated signs, this pigmentation tends to have a blotchy appearance and lacks the fine granularity seen in VKC.[3]

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


Conflicts of interest

There are no conflicts of interest.


1Rao SK, Padmanabhan P. Perilimbal conjunctival pigmentation in vernal keratoconjunctivitis: A new sign. Cornea 2002;21:432.
2Rao SK, Meenakshi S, Srinivasan B, Baluswamy S. Perilimbal bulbar conjunctival pigmentation in vernal conjunctivitis: Prospective evaluation of a new clinical sign in an Indian population. Cornea 2004;23:356-9.
3Luk FO, Wong VW, Rao SK, Lam DS. Perilimbal conjunctival pigmentation in Chinese patients with vernal keratoconjunctivitis. Eye (Lond) 2008;22:1011-4.
4Kumar S. Vernal keratoconjunctivitis: A major review. Acta Ophthalmologica 2009;87:133-47.