Scraping Of Ulcer Base Hastens The Healing Of Grade 3 Shield Ulcer In Vernal Keratoconjunctivitis.
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A 10-year-old boy presented with complaints of pain and photophobia in the left eye. Slit lamp examination revealed cobble stone papillae in both tarsal conjunctivae, diffuse punctate epitheliopathy of cornea and a 3.5x1.5 mm epithelial defect in the left eye. He was diagnosed to be suffering from bilateral vernal keratoconjunctivitis, with evolving grade 3 shield ulcer in the left eye. Shield ulcer was refractory to the combined regime of topical corticosteroids, dual acting antihistamine and lubricating eye drops.
After removal of plaque and scrapping of base, the ulcer re-epithelialized completely in two weeks, leaving behind an opacity which stained negatively with fluorescein dye. The patient was followed up for two months and no recurrence of ulcer was noted.
Drug resistant shield ulcer with plaque re-epithelialized rapidly after removal of plaque and scrapping of base of ulcer.
Shield ulcer, vernal keratoconjunctivitis
Shield ulcer is an uncommon, incapacitating corneal manifestation that occurs in 3 to 11% of patients suffering from vernal keratoconjunctivitis(1). To prevent the vision threatening complications of shield ulcer, it should be treated aggressively and appropriately. Treatment of shield ulcer may vary from topical medication to surgical intervention, depending on the grade of ulcer. Removal of plaque and scrapping of base hasten the re-epithelialization of drug resistant shield ulcer.
A 10-year-old boy from Somalia attended our Out Patientâ€™s Department with a history of redness, itching and watering of eyes, which waxed and waned for almost three years. The redness, itching, watering and thick discharge were persistent in both eyes for the past one year, but he was incapacitated by photophobia and pain in the left eye for the past three months only. During the past six weeks, he was applying Livocabastine and Tobramycin-Dexamethasone eye drops four times daily for the diagnosis of severe vernal keratoconjunctivitis. His best corrected visual acuity was 6/18 OD and 6/36 OS. Biomicroscopy revealed bilateral congested conjunctivae, grade 4 cobblestone papillae and diffuse punctate epitheliopathy of cornea, along with a 3.5x1.5 mm epithelial defect in the left eye which stained positively with fluorescein dye. As the inferior part of the ulcer had a clear base while the superior half exhibited obvious inflammatory debris and thick plaque, he was diagnosed to be suffering from bilateral vernal keratoconjunctivitis with evolving grade 3 shield ulcer in the left eye. His visual acuity was compromised because of bilateral superficial punctate epitheliopathy, along with corneal shield ulcer in left eye. Treatment was commenced with Fluorometholone eye drops, four times per day, Olopatadine eye drops, two times per day and Sodium Hyaluronate eye drops, six times per day. After five days, the symptom-complex improved slightly, but the shield ulcer remained essentially unchanged. (Table/Fig 1) Fluorometholone eye drops were replaced with Prednisolone 1% eye drops which were applied four times daily. The patient was examined one week later, but the shield ulcer did not regress appreciably.
(Table/Fig 2)Removal of plaque was advised. After topical anaesthesia, the plaque was removed with the tip of 26 gauge needle and ulcer base was scrapped with the edge of same needle, under the slit lamp. The eye was patched for twenty four hours. After twenty four hour, the earlier regime of topical Prednisolone, Olopatadine and Sodium Hyaluronate was reinstituted.
(Table/Fig 3)Five days after removal of plaque, remarkable decrease in size of the ulcer was noted.
(Table/Fig 4)Twelve days later, the ulcer re-epithelialized almost completely. (Table/Fig 5)Twenty days after removal of plaque, the ulcer healed completely, leaving behind a nebular grade corneal opacity which stained negatively with Fluorescein dye.
(Table/Fig 6) The best corrected visual acuity improved to 6/9 partial in the left eye. The corticosteroids were tapered gradually, and symptoms of vernal keratoconjunctivitis were controlled satisfactorily by Olopatadine and Sodium Hyaluronate eye drops.
The patient was followed up for two months, and the ulcer did not recur.
VKC is a chronic seasonally exacerbated allergic inflammation of the ocular surface involving the tarsal and/or bulbar conjunctiva (2). VKC is not a blinding disease, but visual impairment is not uncommon if the cornea is involved. Although punctate epitheliopathy is the commonest, shield ulcer with or without plaque, keratoconus, hydrops, pseudogerontoxon and corneal opacification, are not uncommon manifestations of corneal involvement in VKC (3). Coalescence of punctate erosion may lead to a large epithelial defect known as shield ulcer. In the event of inappropriate or no treatment, a plaque containing fibrin and mucus deposits on this epithelial defect which hampers the re-epithelialization of shield ulcer (4). In the treatment of shield ulcer, topical antihistamines, dual action drugs, lubricants and corticosteroids are the first line of defence. Supratarsal corticosteroid injections(5), topical cyclosporine(6), cryotherapy, surgical or laser(7) assisted excision of giant papillae with(8) or without mitomycine, excimer laser phototherapeutic keratectomy(9), amniotic membrane graft(10) and cultivated corneal epithelial cells transplant(11), have been tried for non-healing shield ulcer with varying degrees of success. Recalcitrant shield ulcers may progress to visual threatening complications such as infective keratitis, corneal opacity, perforation, strabismus and amblyopia, and should be treated appropriately and aggressively. Based on their clinical characteristics, response to treatment and complications, shield ulcers can be classified into three grades (12). Shield ulcers with a clear base [Grade 1] have a favourable outcome and re-epithelialize with mild scarring on medical treatment. Ulcers with visible inflammatory debris in the base [Grade 2] exhibit poor response to medical therapy. Because of delayed re-epithelialization shield ulcers may develop infective keratitis. Grade 2 shield ulcers, unresponsive to combined therapy with topical corticosteroids, Olopatadine and lubricating eye drops heal rapidly after adding commercially available preparations of topical cyclosporine (13). Shield ulcers with elevated plaque [Grade3] need surgical intervention (14). On histopathological examination, plaques are found to have granular and deeply oeosinophilic lamellar material attached to the Bowman layer. Immunohistochemistry confirmed this lamellar material to be oeosinophil derived major basic protein (MBP), which possesses cytotoxic properties, and is probably responsible for the delayed ulcer healing (15).
The Shield ulcer in this patient exhibited all three stages of evolvement of shield ulcer which re-epithelialized rapidly after removal of plaque and scraping of ulcer base.
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