Perilimbal Bulbar Conjunctival Pigmentation in Vernal Conjunctivitis

Ocular surface pseudoepitheliomatous hyperplasia secondary to allergic eye disease: clinical features and management

PURPOSE

To study the clinical characteristics and treatment outcomes of ocular surface pseudoepitheliomatous hyperplasia (PEH) associated with chronic vernal keratoconjunctivitis (VKC).

METHODS

This retrospective study includes 39 eyes of 32 patients with VKC induced PEH who presented from 2016-2022. A database search was conducted for diagnosis of PEH, and data on clinical features, imaging characteristics, and treatment were analyzed.

RESULTS

Of the 32 patients, 11 (34%) were children and adolescents, 21 (66%) were adults. PEH was common in males (72%) and ocular surface squamous neoplasia (OSSN) was the commonest referral diagnosis (43.7%). Mean age at presentation was 26.62 ± 10.18 (range: 6-52) years. While history of VKC was present in 21 patients, 11 were diagnosed with VKC at the time of diagnosis of PEH. The mean base/largest diameter was 5.2 ± 1.67 mm. Anterior segment optical coherence tomography (AS-OCT) showed irregular hyper-reflective epithelium, epithelial dipping, and sub-epithelial hyper-reflective lesion with shadowing in all lesions. Of the 31 eyes that received medical therapy, 21 (67%) and 10 (32%) eyes showed complete and partial resolution respectively with median time to resolution of 3(IQR:2-4) months. Eight eyes that underwent surgical excision showed complete resolution and one developed partial limbal stem cell deficiency.

CONCLUSION

Ocular surface PEH is a manifestation of chronic VKC which closely mimics OSSN. Detailed history-taking, examination for signs of allergy, and AS-OCT imaging can distinguish it from OSSN. It responds well to medical therapy and should be considered first-line therapy before planning any surgical intervention.

Pigmented pyogenic granuloma of the cornea and conjunctiva: a rare bilateral presentation

Pyogenic granuloma, also known as lobular capillary hemangioma, is a benign vascular lesion that primarily affects the skin and mucous membranes. It is not pyogenic; nor is it granulomatous. It typically arises in response to local trauma or surgery, irritation, hormonal changes, or chronic inflammation, and it sometimes occurs spontaneously. The occurrence of pigmented pyogenic granuloma in the conjunctiva and cornea without any history of trauma or surgery is extremely rare, particularly in children. We report the clinical presentation, diagnostic evaluation, and successful management of bilateral biopsy-proven conjunctival and corneal pigmented isolated pyogenic granuloma in an 11-year-old girl. No signs of recurrence were seen at the 3-months follow-up.

An observational study on the presence of perilimbal conjunctival pigmentation in vernal keratoconjunctivitis

Purpose

To evaluate presence of perilimbal pigmentation (PLP) in Indian patients with vernal keratoconjunctivitis (VKC). Methods: A cross sectional study was conducted from 2019 to 2020 at a tertiary eye care center in Western Maharashtra, India. In this study, 152 cases of VKC were identified. The presence, type, color, and extent of PLP were recorded. The incidence of presence of PLP was calculated. Its correlations with severity and duration of VKC were analyzed using Wilcoxon-Mann-Whitney U test and Chi square test.

Results

Of 152 cases, 79.61% were males. Mean age at presentation was 11.4 ± 5.6 years. The characteristic PLP was present in 81 cases (53.29%; 95% confidence interval [CI]: 45.03%-61.42%; P < 0.001), of which 15 cases (18.5%) had this pigmentation in all the four quadrants. There was a significant difference between the groups with respect to quadrants involvement in terms of the extent of PLP in clock hours (χ² = 73.85, P < 0.001). However, the extent did not correlate with age (rho = 0.08, P = 0.487), sex (P = 0.115), time since onset in months (rho = 0.03, P = 0.77), duration of VKC and type or color of PLP (P = 0.12).

Conclusion

Perilimbal pigmentation seems to be a consistent clinical finding seen in a significant number of VKC cases. It may benefit ophthalmologists in treating VKC cases when the palpebral/limbal signs are elusive.

Adult vernal keratoconjunctivitis

PURPOSE OF REVIEW

Vernal keratoconjunctivitis (VKC) is a rare chronic self-limiting allergic inflammatory disease of the ocular surface mostly affecting young boys in their first decade of life. In the last few years a new clinical entity of VKC has been described: adult VKC. Two variants have been identified according to clinical onset: early (childhood VKC persisting beyond puberty) and late onset (arising de novo in adults) adult VKC. Several epidemiologic studies on VKC have been published from single tertiary centers but while the age distribution of VKC patients does show a small percentage of adults with the disease, detailed analysis on this small subset of adult VKC cases is lacking. In this review we describe pathogenesis, clinical features, diagnostic alternatives, and therapeutic alternatives of this highly invalidating disease.

RECENT FINDINGS

Adult variants of VKC have same clinical manifestations of classic form, but show higher inflammatory response and increased risk of chronic fibrotic sequelae.

SUMMARY

Adult VKC research could provide insights on the impact of sex hormones in the pathogenesis of allergic diseases and on the mechanisms of inflammation and fibrosis, which cause potentially vision threatening sequelae. The present review will highlight the recent developments in our understanding of this uncommon entity.

Immunopharmacology in Vernal Keratoconjunctivitis: Current and Future Perspectives

Vernal keratoconjunctivitis (VKC) is a complex and chronic, multifactorial Th2 cell-mediated chronic ocular surface inflammatory condition that typically affects predominantly male children in hot or warm climates. The primary symptom is intense ocular pruritus, often significant enough to affect activities of daily living. Clinical features differ from simple forms of allergic conjunctivitis in that they are more-or-less confined to the superior tarsus and limbus. There is also a risk of corneal involvement, which leads to irreversible vision loss in approximately 6% of patients. Right now, there is no standardized treatment protocol, and many of the currently available options are not effective in severe and recurrent cases. As such, it is imperative to understand this complex allergic immune response in order to identify future therapeutic targets. This review will focus on potential drug targets in VKC, with particular emphasis on immunomodulators and immunobiologic agents.

Quality of life and clinical characterization of patients with vernal keratoconjunctivitis in a pediatric population in Colombia

Vernal keratoconjunctivitis is one of the most serious ocular allergies that have the potential to induce large ocular morbidity and significant visual changes affecting the quality of life of these individuals.

METHODOLOGY

This study was conducted in two phases. The first phase consisted of the clinical characterization of 32 patients from the Clinical Allergology center of the I.P.S. Universitaria from July 2014 to February 2015. A retrospective analysis of medical records was performed. In the second phase, the evaluation of quality of life was conducted using the questionnaire KIDSCREEN 27, which was validated in our population and evaluated as recommended by the creators of this instrument.

RESULTS

A total of 24 patients (75%) were men, mean age of 12.1 (SD 2.6) years. 100% of the patients had clinical evaluation and were monitored by Allergology and Ophthalmology, 12 patients (37.5%) were found in mild level, 5 patients (15.6%) were moderate and 14 patients (43.8%) were severe level. The most common symptoms were pruritus (75%), photophobia (50%), lacrimation (37.5%), and secretions (28.1%). 65.6% had a family history of atopy and 84.4% had an allergic comorbidity. Aeroallergen skin tests were found positive in 25 patients (78.1%). All patients had initiated ocular treatment by the time the survey of quality of life was conducted; but, they still had low quality of life scores in the 5 domains assessed. When the scores were evaluated by gender, the only statistically significant difference was found in the domain of family life and free time, which was lower for women.

CONCLUSION

The vernal keratoconjunctivitis is a disease more prevalent in men. It apparently has an important atopic base in our environment, which due to its severe ocular involvement causes a marked decrease in the quality of life of the children who present it.

Impact of Vernal Keratoconjunctivitis on School Children in Egypt

PURPOSE

To evaluate the prevalence of vernal keratoconjunctivitis (VKC) and its impact on school children in Egypt.

METHODS

A total of 3,706 students from six randomly selected schools of Menoufia were included where 126 had symptoms according to the VKC related symptoms questionnaire. Selected children were referred to a hospital for further assessment.

RESULTS

The mean age of included children was 8.79±31.87 years, with a VKC prevalence of 3.3%, and male-to-female ratio of 2.3:1. The most frequently reported symptoms were ocular itching, followed by burning sensation, tearing, red eye, discharge, and photophobia. Signs vary between mild and severe cases; however, all cases had a negative impact on school attendance and performance.

CONCLUSION

The prevalence of VKC differs according to the age group of included cases and the local temperature of the study area. School attendance, performance, lifestyle, and social activities were negatively affected by VKC.

Demographic and clinical profile of vernal keratoconjunctivitis at a tertiary eye care center in India

Purpose:

To study the demographic and clinical profile of patients with vernal keratoconjunctivitis (VKC) at a tertiary eye care center in India.

Materials and Methods:

Retrospective chart analysis of 468 patients of VKC seen from January 2006 to December 2006.

Results:

Mean age at presentation was 12 years. Majority of the patients had mixed pattern disease (72%). Chronic perennial disease was seen in 36% patients. Personal or family history of allergies was noted in 5% patients. Severe disease based on clinical grading was present in 37% patients. Moderate to severe vision loss was seen in 12% of total population. Persistent disease beyond 20 years of age was found in 12% patients. VKC-related complications such as corneal scarring (11%), shield ulcer (3%), keratoconus (6%), and limbal stem cell deficiency (1.2%) were seen. Treatment-related complications like corticosteroid-induced cataract and glaucoma were seen in 6% and 4% of patients, respectively.

Conclusion:

Clinical pattern of VKC seen in the tropical climate of India is essentially similar to that seen in other tropical countries. Few distinct features that we noted represent chronic perennial disease, low association with atopy, and higher propensity for disease and treatment-related complications.

Clinical and Cytologic Evidence of Limbal Stem Cell Deficiency in Eyes With Long-Standing Vernal Keratoconjunctivitis

PURPOSE

We aimed to study the impression cytology (IC) of the ocular surface in eyes with vernal keratoconjunctivitis (VKC) and clinical evidence of limbal stem cell deficiency (LSCD).

DESIGN

This is a prospective comparative study.

METHODS

This study included 78 eyes of 40 patients with VKC. Limbal stem cell deficiency was diagnosed clinically based on the presence of corneal findings such as dull irregular epithelial reflex, superficial neovascularization, conjunctivalization, and loss of limbal palisades of Vogt. The study group consisted of 28 eyes of 15 patients with clinically diagnosed LSCD and control group of 50 eyes of 25 patients without LSCD. Conjunctival and corneal IC was done in all eyes. Presence of goblet cells in the corneal samples on IC was considered confirmatory of LSCD.

RESULTS

Compared with controls, patients with LSCD were older and had longer duration of disease. On IC, goblet cells were present on the cornea in 53.6% of eyes with clinically diagnosed LSCD and in none of the control eyes (P < 0.0001). Clinically diagnosed LSCD in study eyes correlated with cytologic findings of greater conjunctival squamous metaplasia, decreased conjunctival goblet cells, greater corneal cell metaplasia, and increased inflammation as compared with control eyes.

CONCLUSIONS

Most of the eyes with VKC and clinical evidence of LSCD have cytologic evidence of LSCD with goblet cells on the cornea.

[Tropical endemic limboconjunctivitis (vernal conjunctivitis) in northern Cameroon]

INTRODUCTION

A retrospective study was conducted in the ophthalmology unit of the Garoua regional hospital on children examined from January 2001 to December 2007. We aimed to determine the epidemiological aspects of tropical endemic limboconjunctivitis in northern Cameroon. Included were all the files of patients aged 0-15 years seen with a positive diagnosis of tropical endemic limboconjunctivitis. The data analyzed were obtained through inspection, interview, and a comprehensive ocular exam done for every case, assessing far visual acuity, slit lamp biomicroscopy, and funduscopy when possible. The variables analyzed were age, sex, signs and symptoms, residential area, associated pathologies, and the month and the year of the diagnosis. The data were analyzed with Epi-Info, version 6.04d (French) and the results compared with the Chi(2) test with a 95% confidence interval.

RESULTS

A total of 6453 children were included: 2036 had a positive diagnosis of tropical endemic limboconjunctivitis, with a frequency of 31.55%. The mean age was 6.5 years. The 1- to 4-year-old age group had the highest number of patients, with a frequency of 33.25%. There were 1120 males (55%). Itching was the most frequent complaint encountered in 60.90% of the patients. Ocular involvement was always bilateral. Tropical endemic limboconjunctivitis is an allergic conjunctivitis present throughout the year with two peaks in March and July.

DISCUSSION

Tropical endemic limboconjunctivitis can be considered an allergic conjunctivitis affecting boys more frequently than girls in warm and dry environments. It is frequent in children less than 5 years old and regresses with age.

CONCLUSION

Tropical endemic limboconjunctivitis is a tropical disease with an intertropical aspect.

Ocular surface disease: a case of vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a recurrent, chronic allergic inflammation of the ocular surface associated with remodeling of the cornea and conjunctiva, with a potential to adversely affect the patient's vision and quality of life. It affects mainly children and young adults. The purpose of this interventional case report is to present a typical case of limbal VKC, which was unresponsive to antiallergic treatment alone. A 5-year-old boy, who was previously unsuccessful with conventional anti-allergic therapy alone, presented with clinicopathological features pathognomonic of limbal VKC. The patient was successfully managed with a combination of palliative, anti-allergic and anti-inflammatory therapy. Prophylaxis with an anti-allergic pharmaceutical agent was initiated for long term use to prevent the release of allergic mediators. This case highlights the importance of prescribing the most appropriate pharmaceutical medication for VKC since conjunctival fibroproliferative lesions are often resistant to anti-allergy therapy. Allergic inflammatory mediators are responsible for the fibroproliferative changes of the conjunctiva and corneal lesions in VKC. Thus, it is crucial to prescribe the most appropriate pharmaceutical medication that will prevent the release of allergic inflammatory mediators, control the allergic inflammatory cascade and prevent ocular surface damage. The fine points of this case are presented with a review of applicable literature.

Vernal keratoconjunctivitis: a major review

Vernal keratoconjunctivitis (VKC) is a chronic, bilateral, at times asymmetrical, seasonally exacerbated, allergic inflammation of the ocular surface, involving tarsal and/or bulbar conjunctiva. Though the allergic nature of this entity has been accepted for a long time, the accumulation of a large amount of immunological data has proved that the pathogenesis of VKC is much more complex than a mere type 1 hypersensitivity reaction. In the past several years, many clinical and experimental studies about the cells and mediators involved in initiating and perpetuating the ocular allergic inflammation have shown that T helper type 2 cells and their cytokines, corneal fibroblasts and epithelium along with various growth factors play an important role in the pathogenesis of VKC. Based on this information about the pathogenesis of VKC newer, more selective drugs like anti-chemokine receptor antibodies and leukotriene receptor antagonists are under evaluation. Cyclosporine has been shown to be effective in the treatment of VKC but further randomized control trials are required to establish the minimum effective concentration.

Perilimbal conjunctival pigmentation in Chinese patients with vernal keratoconjunctivitis

PURPOSE

To document the disease spectrum and evaluate the presence of perilimbal conjunctival pigmentation in Chinese patients with vernal keratoconjunctivitis (VKC).

METHOD

A case-control study was conducted between November 2004 and July 2005. Patients aged 18 or younger with VKC and age-matched children attending our eye clinic for refractive or orthoptic problems were recruited and compared. Detailed slit-lamp examination was performed noting in particular the presence of perilimbal conjunctival pigmentation, the severity of papillary reaction, and corneal complications of VKC.

RESULTS

A total of 19 patients and 23 controls were evaluated. The presence of bilateral large tarsal or limbal papillae and epithelial defect were significantly associated with symptoms severity (Fisher's exact test, P=0.015 and P=0.035 respectively). All VKC patients were found to have perilimbal conjunctival pigmentation in at least one eye. There was a significant correlation in the colour and density of pigments between the two eyes (Sperman's rho=0.93, P<0.001). None of the controls was found to have such perilimbal conjunctival pigmentation (Fisher's exact test, P<0.001).

CONCLUSION

The presence of perilimbal conjunctival pigmentation appears to be a consistent clinical finding in Chinese patients with VKC and may be a useful diagnostic sign for patients with subtle signs or symptoms.

Conjunctival malignant melanoma-associated pseudomelanoma of the apposing tarsal conjunctiva

PURPOSE

To describe a case of conjunctival malignant melanoma associated with pseudomelanomatous alteration of the apposing tarsal conjunctiva.

METHODS

A 93-year-old woman presented with an elevated, pigmented mass on her superior bulbar conjunctiva. The tumor was associated with increased pigmentation of the apposing superior tarsal conjunctiva. An excisional biopsy of the epibulbar melanoma and pigmented tarsal conjunctiva was performed.

RESULTS

Histopathologic evaluation of the epibulbar tumor revealed epithelioid melanocytes diagnostic of malignant melanoma. Histopathologic evaluation of the pigmented tarsal lesion showed large areas of ulceration and foci of granulation tissue composed of neovascular sprouts arising in the background of a loose connective tissue, with a moderate chronic inflammatory infiltrate. The infiltrate was composed of mature lymphocytes, plasma cells, and scattered histiocytes. Densely packed intracytoplasmic, brown pigment granules that stained positive with HMB 45 were found, attesting to adjacent melanocytes' releasing melanin-laden granules. There was no evidence of malignancy in the pigmented tarsal specimen.

CONCLUSION

Noncontiguous pigmented conjunctival tumor can be found in apposition to an epibulbar melanoma. Although a limited biopsy could be considered, only a complete resection and histopathologic evaluation can determine whether the entire lesion is free of malignant melanoma.