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