Ocular Surface Disease: A Peculiar Case Of Allergic Keratoconjuntivitis Complicated With Nodular Scleritis In Prepubescent Adolescent

Allergic keratoconjuntivitis (AKC) is one of the most common ocular surface 
pathologies and may affect several ocular structures namely the cornea. We present a case of 
vernal keratoconjuntivitis (VKC) complicated with scleritis, thus to review the complications of 
AKC, the therapeutic options available and the challenges in chronic management and its 
asssociation with scleritis. VKC is usually detected on prepubescent males (ages 5-20 and it
peaks at 11-13), affects twice more males than females, with clinical course worsening in 
summer and spring and improving in Winter. (1) If left untreated, VKC can cause corneal 
neovascularization, scarring, or erosions/ulcers or conjunctival scarring, more rarely
scleritis/episcleritis. 

 Unlike VKC, scleritis is more often seen in females, older/adult patients and is 
commonly associated with a systemic autoimune disorder , however infectious and traumatic causes and atopy must not be overlooked. (2) Oral therapy ( NSAIDS/ steroids) is preferred over topical agents.

A 13-year-old adolescent presented at 11 with bilateral keratoconjunctivitis, 
with complaints of ocular pruritus and red eye, as well as, upper tarsal papillae and corneal 
erosions, leukoma and limbal nodules (Horner-Trantas dots). A previous episode of vascular 
limbic pannus occured and was treated with topical bromofenac. BCVA OD and OS 10/10
remained throughout his follow-up.- He was treated with a prophylatic regimen of anti-H1 
blocker/ mast cell degranulation inhibitor(olopatadin) and with multiple courses of topical 
corticosteroid on exacerbations, with progressive improvement of the corneal lesions, despite 
some relapses of symptons and inflammation specially in Spring. However, he developed a 
temporal nodular lesion in OS associated with a scleritis process. The nodular scleritis persisted 
despite the therapy instituted. After carrying out an extensive immunological and serological 
panel, most common systemic and infectious diseases were ruled out. Immunoallergic tests 
reveal sensitization to dust mites and pollens, pointing to an allergic etiology. No history of 
systemic atopic disease (rhinitis, atopic dermatitis and asthma) was found. The patient was 
proposed to start topical mmunomodulatory cyclosporin to improve control of VKC and 
scleritis.

Optimal control of vernal keratoconjuntivitis is crucial to 
avoid long-term complications. Here we showed a case of severe VKC associated with scleritis, 
rarely seen in children. After exclusion of other ethiologies, we related the occurence of 
nodular scleritis with the severity of atopy and emphasing the need for a treatment 
intensification with immunomodulatory drugs, even in children.(3)