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   Table of Contents      
Year : 2003  |  Volume : 51  |  Issue : 1  |  Page : 79-80

Recurrent shield ulcer following penetrating keratoplasty for keratoconus associated with vernal keratoconjunctivitis.

L V Prasad Eye Institute, Hyderabad, India

Correspondence Address:
P Garg
L V Prasad Eye Institute, Hyderabad
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Source of Support: None, Conflict of Interest: None

PMID: 12701868

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Though penetrating keratoplasty for keratoconus secondary to vernal keratoconjunctivitis (VKC) invariably carries a good prognosis, the postoperative course may be complicated by recurrent epitheliopathy. Despite good medical control of VKC shield ulcer is still a possibility.

Keywords: Shield ulcer, keratoconus, vernal keratoconjunctivitis, penetrating keratoplasty

How to cite this article:
Garg P, Bansal AK, Sangwan VS. Recurrent shield ulcer following penetrating keratoplasty for keratoconus associated with vernal keratoconjunctivitis. Indian J Ophthalmol 2003;51:79-80

How to cite this URL:
Garg P, Bansal AK, Sangwan VS. Recurrent shield ulcer following penetrating keratoplasty for keratoconus associated with vernal keratoconjunctivitis. Indian J Ophthalmol [serial online] 2003 [cited 2020 Jul 6];51:79-80. Available from: http://www.ijo.in/text.asp?2003/51/1/79/14732

The association of keratoconus with vernal keratoconjunctivitis (VKC) is well known. [1],[2],[3] However, there are a few reports on penetrating keratoplasty (PK) for keratoconus associated with VKC.[3], [4] We report one case of postoperative reactivation of VKC with consequent superficial vascularisation, punctate epithelial erosions and shield ulcer in the graft even though the surgery was performed after the disease was medically controlled.

  Case Report Top

A 14-year-old female underwent PK with cataract extraction and posterior chamber intraocular lens implantation in the left eye for keratoconus and corticosteroid-induced cataract in May 1999. She had been treated for vernal keratoconjunctivitis since 1993. At the time of surgery the eye was symptom-free, with topical sodium chromoglycate (2%) and polyvinyl alcohol (1.4%). Surgery was performed using a 7.7 mm donor button on 7.7 mm recipient opening and 16 interrupted 10.0 nylon sutures. Postoperatively, she was treated with topical prednisolone acetate (1%) four times a day and polyvinyl alcohol (1.4%) six times a day. At the one-month follow-up she presented complaining of a pricking sensation in the left eye. The tarsal conjunctiva of the upper lid showed papillary reaction [Figure - 1]a. The bulbar conjunctiva was hyperemic. The graft showed diffuse punctate epithelial erosions. There was superficial vascularisation between the 10 and 2 'o clock positions extending up to the graft host junction. There were two loose sutures, which were removed [Figure - 1]b. She was subsequently managed with tapering doses of topical prednisolone acetate (1%) and polyvinyl alcohol (1.4%), and was followed up every 4 weeks.

Nine months following surgery, she complained of marked itching, watering, redness and decreased vision in both eyes. She was using topical prednisolone acetate (1%) once daily and polyvinyl alcohol (1.4%) six times a day in the left eye. Her visual acuity had reduced from 6/15 to 6/36. The tarsal conjunctiva of the left upper lid showed severe papillary reaction [Figure - 2]a. The bulbar conjunctiva was injected. The graft showed an oval area of epithelial defect at the 12 o' clock position near the graft host junction measuring 2.5 x 1.2 mm in size [Figure - 2]b. The margins of the defect were elevated and the ulcer bed was transparent. The surrounding cornea showed multiple punctate epithelial erosions. Corneal scraping from the base of the ulcer showed plenty of eosinophils but no organisms.

She was diagnosed with reactivation of VKC with shield ulcer involving the graft. She was prescribed bandage contact lens (BCL) and topical fluorometholone (0.25%) six times a day, sodium chromoglycate (2%) four times a day and polyvinyl alcohol (1.4%) six times a day. Initially the shield ulcer regressed though it recurred at the same site after 2 months and subsequently after 4 months. At the last follow-up (20 months) her best-corrected visual acuity was 6/15, intraocular pressure was 14 mmHg, and the graft was clear except for the scar at the site of shield ulcer.

  Discussion Top

VKC generally is a benign and self-limiting condition, but has the potential to produce serious complications. In addition to the complications associated with longterm corticosteroid use, recurrent or persistent epitheliopathy and shield ulcer may result in corneal scarring, vascularisation, sterile stromal melt and even corneal perforation.[2] This may also predispose the cornea to infectious keratitis.[2],[3] These complications could ultimately affect graft survival should the reactivation of VKC with associated epitheliopathy occur in an eye with corneal graft. Although Mahmood and Wagoner reported a good outcome (92.2% clear grafts), 7.7% of eyes in their series had bacterial keratitis.[4] Cameron and associates have also shown that the outcome of corneal grafts in keratoconus is usually better in eyes without keratoconjunctivitis (98.8%) than ones associated with keratoconjunctivitis (80%).[3]

Our 14-year-old patient had multiple recurrences of VKC, with progressive superficial vascularisation near the superior graft-host junction, premature suture loosening (within 4 weeks) and epithelial keratopathy manifesting as punctate erosions and shield ulcer. A Medline search of the literature in English using PubMed did not yield any report of shield ulcer on a corneal graft. Although the graft was clear at the last visit (February 2001), it required close follow-up.

Based on our experience with this case as well as a case series of Cameron et al[3] we feel that the corneal transplantation should not be performed during an active or medically controlled phase of VKC. Deferring surgery until the disease becomes inactive could be more rewarding. A close monitoring is mandatory when PK is done in younger subjects.

  References Top

Khan MD, Kundi N, Saeed N, Gulab A, Nazeer AF. Incidence of keratoconus in spring catarrh. Br J Ophthalmol 1988;72:41- 43.  Back to cited text no. 1
Tabbara KF. Ocular complications of vernal keratoconjunctivitis. Can J Ophthalmol 1999;34:88-92.  Back to cited text no. 2
Cameron JA, Al-Rajhi AA, Badr HA. Corneal ectasia in vernal keratoconjunctivitis. Ophthalmology 1989;96:1615-23.  Back to cited text no. 3
Mahmood MA, Wagoner MD. Penetrating keratoplasty in eyes with keratoconus and vernal keratoconjunctivitis. Cornea 2000;19:468-70.  Back to cited text no. 4


  [Figure - 1], [Figure - 2]

This article has been cited by
1 Penetrating keratoplasty for keratoconus with or without vernal keratoconjunctivitis
Wagoner, M.D., Ba-Abbad, R.
Cornea. 2009; 28(1): 14-18
2 Difficulties of corneal graft surgeries in Bahrain - Reasons for failure
Hassan Al-Yousuf, N.S.
Bahrain Medical Bulletin. 2003; 25(3): 103-104


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