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19 year old man with a "corneal abrasion"
Digital Journal of Ophthalmology 1997
Volume 3, Number 15
March 18, 1997
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Yichieh Shiuey, MD | Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
Kathy Colby, MD | Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
Claes Dohlman, MD | Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
Diagnosis and Discussion
Vernal Keratoconjunctivitis

Clinical Course:
Four weeks after presenation the patient still had persistent epithelial staining with subepithelial haze. Cyclosporine 1% was started in addition to pred forte bid. Over the following 2 months the patient had resolution of his shield ulcer OD. The papillae of the right superior tarsus partly regrew. Six months after presentation the patient had complete resolution of his symptoms and was 20/20 OU.

Background:
The term vernal is derived FROM the Greek and means "occurring in the spring." Despite, this name, vernal keratoconjunctivitis (VKC) may occur during any season, although some patients do have seasonal exacerabtions. VKC has several interesting epidemiologic characteristics. Typically, it occurs more commonly in warm climates than cooler climates. It is often associated with a history of atopic disease such as asthma, allergic rhinitis, and eczema. There is also a male predominance with a male to female ratio of at least 2:1. Onset of the condition is frequently at puberty with remission occuring often by the late teens.

Clinical Features:
Patients usually present with symptoms of severe itching. Photophobia and pain may also be present if the corneal epithelium has been damaged. Because the symptoms of VKC may not differ significantly FROM those of seasonal allergic conjunctivitis, it is very important to evert the upper lids to rule out this entity.

The most characteristic examination finding of VKC are large raised conjunctival papillae on the upper tarsus. These "cobblestones" are almost never found on the lower tarsus. The upper lids may become so heavy FROM the presence of these cobblestones that a mechanical ptosis may result, as was the case in our patient. A tenacious stringy mucus is always present intertwined between the cobblestones. A well circumscribed sterile "shield" ulcer found on the superior or central aspect of the cornea is very typical of this condition.

There is a variant of VKC which preferentially affects the limbus. This form is more common in patients of African Descent and Asians. Findings in limbal VKC include Horner's Trantas dots which are elevated white superficial infiltrates that straddle the the limbus, with no intervening clear space. Gelatinous nodules representing enlarged limbal papillae are also found in this condition.

Pathophysiology:
It is believed that mast cells and eosinophils play critical roles in the pathogenesis of this allergic disease. Both mast cells and eosinophils are found in increased numbers in the conjunctiva of patients with VKC. The presence of 2 or more eosinophils per high power field in a biopsy of conjunctiva is essentially pathognomonic of VKC.

Treatment:
The first step in treating VKC, as well as all other allergic conditions of the eye, is to identify the allergen. Once the allergen is identified, the patient can then learn to eliminate or avoid the antigen. The aid of an allergist may be very helpful in this regard. Topical therapy may include brief courses of steroids (up to several weeks) to quiet the disease, followed by rapid tapering. Mast cell stabilizers including cromolyn and lodoxamide should be started while the patient is receiving steroids for acute flares since these agents require time for their clinical effects to occur. Once the acute situation is controlled some patients are able to be successfully treated with mast cell stabilizers alone. Other drugs that are being tried include cyclosporine and levocabastine. As was noted above, VKC often spontaneously remits after the late teens.
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