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Itchy eyes with sharp pain
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A 10-year-old African American male presented with symptoms of red itchy eyes. According to his parents, the boy was first seen 1 week ago and treated by his primary care physician with an over-the-counter anti-allergy drop.
After several days of treatment the parents reported no improvement and, in fact, the left eye seemed to be getting worse. The boy stated that his eyes not only itched, but he also experienced sharp pain at times.
The parents then took the child to their family eye doctor, and the child was treated with an antibiotic drop. After 3 more days of treatment the patient showed no signs of improvement. The parents and patient denied any allergies or discharge.
Leo P. Semes
According to the parents, the child took no other medications. The patient was not a contact lens wearer; unaided visual acuities were 20/20-2 OD and 20/25 OS.
Upon completing a slit lamp examination, I found the right eye to have 1+ injection and some slight string-like discharge. The left eye revealed 2+ injection, string-like discharge and grayish-white raised areas around the corneal margins. There was no corneal staining centrally. The upper tarsal plates were clear on the right eye, but the left eye had 1+ papilla. The anterior chamber was free from cell and flare in both eyes.
The left eye revealed 2+ injection, string-like discharge and grayish-white raised areas around the corneal margins.
Images: Matthews D and Rafieetary M
Fundus evaluation was deferred until the eyes were quiet.
When taking a scraping from the limbal conjunctiva, we found eosinophils and eosinophilic granules; however, between the attacks, mast cells were found on the stained slide, but eosinophils were not.
What’s your diagnosis?
Itchy eyes
The primary eye care physician must not just treat this as a simple allergic conjunctivitis. Raised areas surrounding the cornea were noted in the left eye. This can lead to rare total pannus; more likely, however this can lead to superficial ulcers and scarring.
When we speak of an allergic response, we are talking about the immune system’s reaction to foreign substances commonly known as immunogens or allergens. The key to allergic conjunctivitis or, more specifically, vernal conjunctivitis is the eosinophil – vernal or limbal vernal conjunctivitis, which is IgE-mediated, is the only ocular disease to develop a solely type 1 hypersensitivity.
This image of another patient shows classic vernal conjunctivitis with ulceration. Because corneal ulcer can be a secondary effect of vernal conjunctivitis, treatment with a steroid-antibiotic combination is recommended.
Images: Matthews D and Rafieetary M
According to Sowka and colleagues, “the involvement of the secondary inflammatory cells – particular eosinophils (along with mast cells) resident to the substantia propria of the superior tarces – can produce sequelae. Papillae, with epithelial downgrowth from crypts (at the base of which lie mucus), produce goblet cells. Plasma cells and lymphocytes will collect inside the papilla stroma. Vernal shield ulcers may also develop in the upper region of the cornea.”
The ulcer at its base is primarily made up of abnormal mucus, serum and fibrin deposits that appear as a grey plaque. This leads to an irritated response, causing conjunctiva to erode.
Vernal keratoconjunctivitis (VKC) can present in three different clinical forms.
The palpebral form can involve the tarsal plate of either eye. The lesion is typically characterized by the presence of hard, flat papillae arranged in a cobblestone appearance. In severe cases the papillae may look like cauliflower or giant papillae.
The bulbar form usually presents as a dusky, red, triangular congestion of the bulbar conjunctiva in discrete whitish raised dots along the limbus (Trantas’ spots).
The mixed form is a combination of both palpebral and bulbar types.
The management of VKC is aimed at reducing the symptoms, thus reducing the risk of serious vision loss and threatening sequelae. The most effective treatment is to avoid or eliminate the allergen that may be responsible for the particular allergy attack. However, in many cases this is either impractical or just plain unrealistic.
It is sometimes suggested that we use cold compresses and tear substitutes. This tends to dilute the antigen. Other treatments such as Bepreve (bepotastine besilate ophthalmic solution 1.5%, Bausch + Lomb), Lastacaft (alcaftadine ophthalmic solution 0.25%, Allergan) and Pataday (olopatadine HCl 0.2%, Alcon) are excellent H1-specific and H1 type drops that may provide relief to the patient. However, when dealing with limbal vernal conjunctivitis, it is best to start out using a steroidal antibiotic combination such as Zylet (loteprednol etabonate 0.5%/tobramycin 0.3% ophthalmic suspension, Bausch + Lomb) or TobraDex ST (tobramycin 0.3%, dexamethasone 0.05% ophthalmic suspension, Alcon) to rid the disease entity.
In cases where shield ulcers occur, one should consider using cycloplegic drops such as homatropine or atropine, along with antibiotic drops such as Vigamox (moxifloxacin ophthalmic solution 0.5%, Alcon), Besivance (besifloxacin, Bausch + Lomb), Zymaxid (gatifloxacin 0.5%, Allergan) or Moxeza (moxifloxacin 0.5%, Allergan). In some cases one would consider a low-water thin hydrogel lens that will reduce the foreign body sensation between the lid and cornea. When the cornea becomes re-epithelialized, we can then initiate topical steroid use.
If the issue becomes chronic, consider treating in advance to get a jump-start on the allergen. By using mast-cell stabilizers and antihistamine drops (cromolyn sodium and H1-specific drops, such as Bepreve) one may be able to retard the degranulation process of the cell, thus reducing or eliminating a histaminic effect.
In this patient, it should be noted that the papilla on the upper lid of the left eye appeared to be the initial sign of vernal conjunctivitis. As the disease progresses, the limbal margins can become involved.
This patient was treated by his primary care physician with over-the-counter antihistamine drops. As a result of this treatment, the lid involvement was not as severe as expected.
Limbal vernal conjunctivitis is found primarily in males between the ages of 3 and 23 years; however, we recently have treated a 36-year-old female with this condition. Treatment consisted of a combination steroid-antibiotic drug for 7 days.
Reference:
- Sowka JW, Gurwood AS, Kabat AG. Handbook of Ocular Disease Management. New York, Jobson Medical Information, October 2002.
For more information:
- Mel A. Friedman, OD, is in private practice with For Your Eyes Only in Memphis, Tenn. He can be reached at Dfried007@aol.com.
- Edited by Leo P. Semes, OD, a professor of optometry, University of Alabama at Birmingham and a member of the Primary Care Optometry News Editorial Board. He may be contacted at (205) 934-6773; lsemes@uab.edu.
- Disclosure: Dr. Friedman is a national consultant for Bausch + Lomb and for Ista Pharmaceuticals.