The damaging shield: An incapacitating presentation of vernal keratoconjunctivitis

Abstract

Vernal keratoconjunctivitis (VKC) is a recurrent, bilateral, seasonal disorder which mostly affects young males. Shield ulcer is an uncommon manifestation of severe form of VKC, seen in 3%–11% of VKC patients, which adversely affects vision. The purpose of this case report is to bring to light that proper timely management can improve visual acuity. A 15-year-old male presented with a complaint of severe itching, with foreign body sensation and redness in BE since 1 week. It was associated with blurring of vision in LE since 2 days. He had history of similar episodes since the past 7 years, usually exacerbating in spring for which he was advised topical steroids and lubricating drops. On examination, RE showed papillae in both upper and lower tarsal conjunctiva. LE showed lid edema, giant cobblestone appearance of papillae in upper and lower tarsal conjunctiva, and a fluorescein stained positive epithelial defect of 3 mm × 4 mm which had elevated plaque containing mucus and debris was noted in the central cornea. He was diagnosed with bilateral VKC with Grade 3 shield ulcer in LE. He was started on topical steroid 4 times and lubricating drops in BE along with topical tacrolimus 0.03% BD in LE. No improvement was noted after 3 days. Margin and base of ulcer with 1 mm of clear margin was scraped and bandage contact lens was put on the 3rd day of starting treatment. On 1 week follow-up of scraping, healing margin was noted with best-corrected visual acuity (BCVA) of 6/60. After 1 month, the BCVA improved to 6/18, and at 3-month follow–up, it improved to 6/9. Shield ulcer, although rare, is an incapacitating vision threatening manifestation of VKC. Timely management of the same is essential to ensure full recovery without any permanent ocular damage. Conservative management should always be considered before surgical treatment in all cases. Various studies are being carried to study the efficacy of immunosuppressive agents especially tacrolimus in treating shield ulcer. Here, we found out that timely instillation of tacrolimus can lead to prompt recovery with significant visual rehabilitation.

Keywords

• giant cobblestone papillae
• shield ulcer
• vernal keratoconjunctivitis