THE IMPORTANCE OF CORNEAL ANGIOGRAPHY IN SUBCLINICAL LIMBITIS IN A CASE OF ATOPIC KERTOCONJUNCTIVITIS

To report corneal angiography features in subclinical limbitis in a patient with atopic kertoconjunctivitis 

A 22-year-old woman was referred for bilateral corneal neovascularization with scarring. Her past medical history was positive for erythema nodous and atopy, as she had been diagnosed with eczema, asthma, hay fever, dust allergy, and atopic keratoconjunctivitis (AKC). She had a past ocular history negative for herpetic keratouveitis, trauma, infections, or use of contact lenses. She was on topical tacrolimus 0.03% ointment twice daily, oral antihistaminic (Cetirizine 10 mg once daily), and occasional courses of eye drops of olopatadine 0.1% and prednisolone 1%, which have been used discontinuously in the past. 

On examination, the best corrected visual acuity (BCVA) was 20/40 in the right eye (RE) and less than 20/200 in the left eye (LE), while the intraocular pressure was 18 mmHg in RE and 8 mmHg in LE. 

At slit lamp examination, the AKC was inactive, and the patient complained only of non-specific discomfort and occasional itchiness. No mucoid discharge, no bulbar conjunctiva hyperemia nor punctate keratitis were present. 

Of note was the bilateral corneal pannus with superficial and deep corneal neovascularization (CoNV) and scarring in both eyes. The state of activity of the corneal pannus was uncertain, as no signs of oedema and leakage were noticeable at biomicroscopy.

To better estimate the possible presence of subclinical ocular surface inflammation activity, the CoNV status, and to plan suitable therapy and monitoring, an anterior segment fluorescein angiography (FA) and indocyanine green angiography (ICGA) were performed. The FA showed limbal leakage at the early phase (around 1 minute after injection), and ICGA dye leakage in the late phase (5-10 minutes after the injection), more pronounced in the left eye and in the superior hemi-cornea. These findings highlighted a subclinical inflammation of the limbus. Late leakage of corneal vessels was also noticed at FA and ICGA.

The patient was recommended to continue treatment with tacrolimus 0.03% ointment twice daily and in both eyes start topical dexamethasone 0.1% six times per day, as well as topical olopatadine 0.1% twice daily, for 8 weeks.

At review, the patient reported feeling better, with less ocular discomfort. The BCVA remained stable and, at slit lamp, the ocular surface appeared unchanged. Limbal FA and ICGA leakage was no longer present, proving the efficacy of the treatment.

Active allergic corneal limbitis may present as subclinical inflammation, with no signs of activity at slit-lamp examination. Therefore, its diagnosis can be challenging without the use of corneal angiography.