Breaking The Shield: Surgical Management Of A Persistent Shield Ulcer In Vernal Keratoconjunctivitis.

To report the case of a pediatric patient with vernal keratoconjunctivitis (VKC) complicated by shield ulcer and subsequent keratoconus (KC), highlighting the importance of timely management to prevent long-term complications and improve quality of life. The case emphasizes the need for surgical intervention in VKC cases unresponsive to medical treatment and discusses the association between VKC and KC.

The case involved a 10-year-old male patient treated in an emergency department of a tertiary care ophthalmology center. The patient lived in a marginal neighborhood with poor hygiene and frequent exposure to animals, contributing to a complex clinical scenario. He had a five-year history of VKC and was previously managed at his referral hospital with topical olopatadine, fluorometholone, cyclosporine A, and autologous serum drops.

The patient presented with a 10-day history of itching, photophobia, redness, and whitish discharge.  Ophthalmologic examination revealed eyelid eczema, giant papillae, hyperemia, and a shield ulcer in the right eye. Initial treatment consisted of tacrolimus 0.1% ointment, tobramycin ointment, topical olopatadine, artificial tears, and oral prednisolone.

Periodic evaluations every 10 days showed no improvement. Surgical intervention was performed, involving resection of the giant papillae, debridement of the shield ulcer, and intratarsal injection of triamcinolone. Post-surgical follow-up was conducted over six months to assess clinical outcomes and recurrence. Corneal topography was performed three months after surgery to evaluate KC.

Initial medical treatment provided minimal relief, with persistent pain, photophobia, and no resolution of the shield ulcer. Surgical treatment resulted in significant improvement, including:

• Resolution of the shield ulcer.
• Elimination of giant papillae, with no recurrence for at least six months.
• Symptomatic relief, allowing the patient to return to school three months post-surgery.

Despite clinical improvement, corneal topography performed three months after surgery confirmed the development of KC, with a maximum corneal curvature of 66.2 diopters and central stromal thinning. This finding corroborates the association between VKC and KC, emphasizing the role of eye rubbing and chronic inflammation in KC progression.

This case highlights the importance of managing VKC promptly to alleviate symptoms, prevent complications, and minimize the progression of associated conditions such as KC. Severe itching in VKC, often leading to habitual eye rubbing, is a significant risk factor for KC development. Surgical resection of giant papillae is a simple, repeatable technique that can effectively manage VKC cases unresponsive to medical treatment. Adjunctive procedures, such as amniotic membrane transplantation, may further enhance outcomes.

Early recognition of VKC and its complications, along with tailored management strategies, is essential to improve quality of life and visual outcomes in pediatric patients.