inferior s hield ulcers in atopic keratoconjunctivitis
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A Loh, PY Boey & RS LohSingapore National Eye CentreWorld Cornea Congress VIBoston, Massachusetts, April 7-9, 2010The authors have no financial interests in the subject matter of this poster
IntroductionAtopic keratoconjunctivitis (AKC) is a bilateral, chronic
inflammation of the conjunctiva and lids associated with atopic dermatitis
There is a male preponderance, with the onset of disease typically in the second to fifth decade
The major symptom is ocular itching which may be seasonal or perennial
Signs include Lids eczema, blepharitis, meibomianitis & tarsal margin
keratinization Conjunctiva sub-epithelial fibrosis, symblepharon, fornix
shortening & giant papillae Cornea superficial punctate keratitis, neovascularization &
persistent epithelial defectsShield ulcers, as defined as an epithelial defect with
intact Bowman’s membrane and an overlying fibrin/mucous plaque, occurring in the superior half of the corneal surface is classically associated with Vernal keratoconjunctivitis (VKC)
In this study we report the incidence of four cases of inferior shield ulcers occurring in atopic keratoconjunctivitis
Materials & Methods IRB review board approvalRetrospective case series in one centre, CGH, from
01/01/05 to 30/12/08The diagnosis was based on the history and
presentation of ocular surface/corneal findingsThe following were assessed -
Risk factors -
Atopic dermatitis
Asthma
Allergic rhinitis
Examination -
Snellen visual acuity
Slit-lamp examination
Goldman tonometry
Results 27 patients (24 bilateral) with allergic ocular disease
were identified in the 4 year study periodAKC was present in 19 of these 27 patients (16 bilateral
disease)Age at onset ranged from 10 to 30 years (mean 18.4 years, median 18).
with a male:female ratio of 4.75:1 (females n=4, 21.1%).Racial preponderance -
Chinese 74.9% (n=15) Malay 25.1% (n=4)
Follow-up period ranged from 4 to 72 months (median 4 weeks)Average recurrence rate was 1 per 4.7 monthsNumber of recurrences ranged from 0 to 5 (median 2)
Results Pre-existing disease at presentation
Asthma 36.8% (n=7) Eczema 63.2% (n=12) Allergic rhinitis 42.1% (n=8)
Family history of atopic disease was present in 31.6% (n=6)Symptoms on presentation
Itch and redness were present in all patients Mucoid discharge 73.7% (n=14) Watering 84.2% (n=16)
Results Visual acuity (VA)
Best corrected VA (BCVA) ranged from 20/20 to 20/120 (median 20/30) with final VA on resolution of 20/20 or better. There was no loss in lines of BCVA.
Minimum BCVA ranged from 20/20 to 20/200 (median 20/40)Slitlamp findings were as follows
Giant papillae 68.4% (n=13) Limbal follicles 31.6% (n=6) Shield ulcers 31.6% (n=6) Corneal scars 26.3% (n=5)
Treatment All patients were treated with topical mast cell stabilizer/anti-histamine
(eg. G Olopatadine 0.1%) and topical steroids (eg. Fluoromethalone 0.5%, Dexamethasone 0.3% and Prednisolone Acetate 1.0%)
Six patients (31.6%) required topical Cyclosporine A (CSA) 0.5% for long term control
There was no incidence of secondary cataract or glaucoma
Results Inferior shield ulcers occurred in 4 patients (21%). This was present in
all cases in the left eye, with one having coincident upper shield ulcer in the fellow eye
All patients were males, 3 were of Chinese and 1 of Malay racial origin. Age at presentation ranged from 12 to 19 years
Pre-existing asthma, atopic disease and/or eczema was present in 3 patients
Bilateral disease was present in 3 patientsBCVA was 20/40 to 20/120 at presentation improving to 20/20 in all
cases with treatment. All shield ulcers resolved within 4 weeks using a combination of topical Olopatadine 0.1% and Prednisolone Acetate 1.0%. Three patients required topical CSA 0.5% as maintenance therapy
Giant papillae were present in 3 patients, with limbal follicles in one
Fig 1. Clinical patterns of inferior shield ulcersa & b – inferior shield with mucous plaquec & d – mucous plaque removed – epithelial defect revealed
Fig 1a Fig 1b
Fig 1c Fig 1d
Fig 2. Other featuresa – inferior pseudogerontoxonb – limbal follicles and meibomiatisc & d – early superior shield ulcer with inferior corneal scar from healed inferior shield ulcer
Fig 2a Fig 2b
Fig 2c Fig 2d
Discussion This study demonstrates that inferior shield ulcers
can occur in atopic eye disease The pathogenesis of inferior shield ulcers in VKC has
been previously described by Buckley Inferior shield ulcers in AKC may be due to a
combination of keratinization of the lid margins, meibomianitis and late presentation for treatment
Visual prognosis in this study group is good The response to topical anti-histamine/mast cell
stabilizers and steroid therapy combination was good although maintenance therapy with topical CSA 0.5% was required in 31% (n=6) of cases. This may partly explain the absence of secondary glaucoma
References1. Buckley RJ. Vernal keratoconjunctivitis. Int Ophthalmol Clin 1988 28:303-3082. Tuft SJ, Kemeny DM, Dart JK et al. Clinical features of atopic keratoconjunctivitis. Ophthalmology. 1991 Feb;98(2):150-853. Foster CS, Calonge M. Atopic keratoconjunctivitis. Ophthalmology. 1990 Aug;97(8):992-10004. Hingorani M, Moodaley L, Calder VL et al. A randomized placebo controlled trial of topical cyclosporin A in steroid-dependent atopic
keratoconjunctivitis. Ophthalmology. 1998 Sept;105(9):1715-205. Anzaaf F, Gallagher MJ, Bhat P et al. Use of systemic T-lymphocyte signal transduction inhibitors in the treatment of atopic keratoconjunctivitis.
Cornea 2008 Sep;27(8):884-8
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