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Year : 1990  |  Volume : 38  |  Issue : 1  |  Page : 33-34

Vernal ulcer

Aravind Eye Hospital & Post Graduate Institute of Ophthalmology, 1, Anna Nagar, Madurai- 625 020, India

Correspondence Address:
M Srinivasan
Aravind Eye Hospital & Post Graduate Institute of Ophthalmology, 1, Anna Nagar, Madurai- 625 020
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Source of Support: None, Conflict of Interest: None

PMID: 2365436

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Vernal ulcer is a rare entity not reported in Indian ophthalmic literature. 76 patients in the age group ranging from 3-43 years diagnosed as having vernal conjunctivitis had been referred from general ophthalmology clinic to cornea service of the same institute during 1988-89. Among them 60 were males and 16 were females. 55 of the 76 patients had corneal involvement in the form of vernal keratitis or vernal ulcer. 16 had typical vernal ulcers. vernal ulcer was found more in the palpebral type of vernal conjunctivitis and affects males more frequently. One patient had an inferior vernal ulcer. It also occurred in the bulbar type of spring catarrh.

How to cite this article:
Srinivasan M, Srinivasan S. Vernal ulcer. Indian J Ophthalmol 1990;38:33-4

How to cite this URL:
Srinivasan M, Srinivasan S. Vernal ulcer. Indian J Ophthalmol [serial online] 1990 [cited 2022 Sep 25];38:33-4. Available from: https://www.ijo.in/text.asp?1990/38/1/33/24549

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  Introduction Top

Vernal ulcer is a rare entity, not found very often in the ophthalmic literature. Jones, B.R. (1961) had reported about vernal keratitis [1]. To our knowledge we have not come across any report about this rare disease in the recent past in our country. Moreover these patients had been diagnosed as having trachoma or phlyctenular kerato conjunctivitis and treated months together else­where. So the aim of this article is to highlight about the vernal ulcer which is said to be a rare manifestation of vernal catarrh.

  Material and methods Top

76 patients in the age group ranging from 3 - 43 years had been examined at the cornea service by the author during 1988-89. All these patients were referred from the general ophthalmic clinic of the same institute. 60 of them were males and 16 were females. Among the 76 patients 36 had palpebral type, 32 had bulbar type, and 8 had the mixed type of vernal catarhh.

All these patients had routine, regular ocular examina­tion at the general ophthalmic clinic. History of allergy and atopic diseases were carefully evaluated. Previous treatment was noted down especially use of topical steroids. Patients who had severe photophobia, blurred vision and watering were sent to the cornea service. Pa­tients with suspected corneal involvement were also examined by the authors. All the patients had severe ble­pharospasm and in some we had to use topical anaes­thetics to have a better view. All the patients were exam­ined under slit lamp. Conjunctival cytology was done using Giemsa stain.

  Observation Top

We diagnosed 16 vernal ulcers. The ulcer was horizon­tally oval, involving the superior half of the cornea, with grey raised borders, and sometimes covered with white mucous plaques. Bacteriologically the vernal ulcers were sterile. Few cases had superfical vascularization in the ulcer bed. Vernal keratitis was found in 34 cases. Four had associated kerataconus and one had pellucid marginal degeneration. The corneal involvement in this study is given in [Table - 1]. The papillae were found more over the superior tarsal conjunctiva and were fairly large in size. [Figure - 1]. We have not seen papillae in the lower palpebral conjunctiva. Even though inferior vernal ulcer is extremely rare we noticed this in a 43 year old male patient [Figure - 2]. The superficial keratitis was more dense over the superior half of the cornea and sometimes it was confluent; stains easily with 2% fluorescein and 1 % rose bengal. Fine superficial vessels were noticed in the upper half of the cornea resembling trachomatous pan­nus. Sometimes the keratitis appears as dusted flour. Epithelial iron pigmentation was observed especially in the bulbar type. The pigmentation was heavy over the exposed part of the bulbar conjunctiva giving rise to a cosmetic blemish. Lid margins and tear miniscus were normal in all patients. Corneal sensation was normal. No lagophthalmos was found. Even though it had been mentioned that this disease is rare above the age of 20 years, one third of our patients were above the age of 20 years. Two third of the patients had severe symptoms in summer. Males were affected more in this study. Most of our patients had been already treated with topical ster­oids, various antibiotics and sodium cromoglycate. Ver­nal keratitis has to be differentiated from nutritional keratitis and dry eye syndrome. In our service we had not seen associated malnutriation or any other systemic disease. Vernal ulcer was found in the bulbar type also in two patients.

  Discussion Top

Corneal manifesatations have been reported in as many as 50% of patients with palpebral type spring catarrh. Fortunately, the incidence of ulcerative keratitis in this disease is much lower, ranging from 3% to 4% [2]. The incidence in our service was 21 %. This high incidence could be explained due to selective patient examination and we have not examined all the patients who had spring catarrh in these two years who were managed at the general ophthalmology clinic. Only patients with se­vere symptoms as photophobia and blurred vision had been included in this study. As in any other study the. males were predominant comprising 79%. Even though. it had been said that the limbal form is more in blacks, our study showed equal distribution of palpebral and limbal type. The corneal involvement was more in males and palpebral type of spring catarrh. Among 16 vernal ulcers only one patient had an inferior vernal ulcer which is ex­tremely rare and was mentioned only once in the litera­ture [3].The vernal ulcer is characteristically transversely oval, shield like in the superior part of the cornea. It is shallow and does not usually become vascularized. An edge of shaggy, greyish white dead epithelium is seen leading to the shallow centre of the necrotic debris. The underlying superficial stroma is infiltrated. The ulcer is in­dolent, does not tend to spread and may be present for weeks, sometimes leaving a permanent corneal opacity at the level of Bowman's layer.

The mechanism of developing vernal ulcer is not exactly known. Many authors attribute it to mechanical rubbing of the cornea by papillae during frequent blinking. Some even tried bandage contact lenses to prevent this. But histology of papillae, conjunctival cytology, response to steroids, seasonal occurence, involving young individu­als are all in favour of the allergic theory. We have seen corneal involvement in 2 cases who had only bulbar type of vernal catarrh. The conjunctival smear of all our patients revealed numerous eosinophils. We treated them with a pulsed dose of topical Dexamethasone tapered and maintained them on topical fluromethalone; 2% sodium cromoglycate was found ineffective in re­leaving symptoms in our patients. One patient of vernal ulcer treated with topical steroids developed hypopyon bacterial ulcer a week after commencement of steroids. Cold compresses,tinted glasses, and cooler climate make the patient comfortable. A warning should be given to all patients who have vernal conjunctivitis about the complications of topical steroids[6].

  References Top

Jones, B. R. Vernal keratitis. Trans.Ophthalmol. Sec. U.K.81 :215, 1961   Back to cited text no. 1
Beigelman, M. Vernal conjunctivitis. Los Angeles, University of Southern California Press. PP 74 - 75, 1950  Back to cited text no. 2
James D. Shuler et el. Interior corneal ulcers associated with palpebral vernal conjunctivitis. A. J. Ophthalmol. 106:106: 1988.  Back to cited text no. 3
Duke - Elder, S: Diseases of the outer eye. In system of Ophthalmology Vol 8.part 1. St. Louis, C. V. Mosby PP484 -485, 1965  Back to cited text no. 4
Merrill Grayson: Diseases of the cornea. The C. V.Mosby PP 290-296, 1979   Back to cited text no. 5
Frederick H. Theodore et al. Clinical allergy and immunology of the eye. Williams and Wilking, pp 46 -49,1983.  Back to cited text no. 6


  [Figure - 1], [Figure - 2], [Figure - 3]

  [Table - 1]

This article has been cited by
1 Corneal complications of spring catarrh
Zeb, A., Awan, A., Hamid, A., Uppal, F., Salani, A.
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2 Keratitis in children as seen in a tertiary hospital in Africa
Ashaye, A., Aimola, A.
Journal of the National Medical Association. 2008; 100(4): 386-390
3 A survey of vernal keratoconjunctivitis and other eosinophil-mediated external eye diseases amongst Palestinians
OæShea, J.G.
Ophthalmic Epidemiology. 2000; 7(2): 149-157


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