A Loh, PY Boey & RS Loh Singapore National Eye Centre World Cornea Congress VI Boston, Massachusetts, April 7-9, 2010 The authors have no financial interests in the subject matter of this poster

Introduction Atopic 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 Conjunctivasub-epithelial fibrosis, symblepharon, fornix shortening & giant papillae Corneasuperficial punctate keratitis, neovascularization & persistent epithelial defects Shield 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 approval Retrospective case series in one centre, CGH, from 01/01/05 to 30/12/08 The diagnosis was based on the history and presentation of ocular surface/corneal findings The 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 period AKC 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 months Number of recurrences ranged from 0 to 5 (median 2)

Results Pre-existing disease at presentation Asthma 36.8% (n=7) Eczema63.2% (n=12) Allergic rhinitis42.1% (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) Watering84.2% (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 scars26.3% (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 patients BCVA 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 ulcers a & b – inferior shield with mucous plaque c & d – mucous plaque removed – epithelial defect revealed Fig 1aFig 1b Fig 1cFig 1d

Fig 2. Other features a – inferior pseudogerontoxon b – limbal follicles and meibomiatis c & d – early superior shield ulcer with inferior corneal scar from healed inferior shield ulcer Fig 2aFig 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 References 1. Buckley RJ. Vernal keratoconjunctivitis. Int Ophthalmol Clin : Tuft SJ, Kemeny DM, Dart JK et al. Clinical features of atopic keratoconjunctivitis. Ophthalmology Feb;98(2): Foster CS, Calonge M. Atopic keratoconjunctivitis. Ophthalmology Aug;97(8): Hingorani M, Moodaley L, Calder VL et al. A randomized placebo controlled trial of topical cyclosporin A in steroid-dependent atopic keratoconjunctivitis. Ophthalmology Sept;105(9): 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