Non-infectious and non-hereditary diseases of the corneal epithelium.

The corneal epithelium serves as a physical barrier and a refractive element. Therefore, diseases of the corneal epithelium can increase the risk for infection and causes vision loss. The corneal epithelium can be affected by a multitude of conditions, such as infections, hereditary diseases, depositions, trauma, autoimmune conditions, factitious disorders, and iatrogenic causes. Non-infectious and non-hereditary corneal epithelial diseases represent a collection of conditions with diverse etiologies and clinical presentations but similar patient symptoms. The differing therapeutic interventions for each condition make clinical distinction important. The clinical characteristics, disease course, pathophysiology and current treatments for non-infectious, non-hereditary corneal epithelial diseases are reviewed.

The spectrum of allergic ocular diseases.

OBJECTIVE: The purpose of this article is to review the pathophysiologic mechanisms, differential diagnosis, evaluation, and treatment of the various manifestations of ocular allergy, with an especial focus on immunoglobulin E (IgE)-mediated disease. DATA SOURCES: A PubMed search was performed to include articles, using the search terms ocular allergy and allergic conjunctivitis. STUDY SELECTIONS: Recent and relevant human studies in the English language pertaining to our topic of study were selected. Animal studies pertaining to pathophysiology of ocular allergy were also reviewed. We focused on clinical trials, practice guidelines, reviews, and systematic reviews. In addition, case reports were reviewed if they described rare clinical presentations, disease mechanisms, or novel therapies. RESULTS: Ocular allergy encompasses both IgE- and non-IgE-mediated disease, and the clinical severity may range from mild to sight-threatening inflammation. A comprehensive treatment regimen including education, lifestyle measures, topical therapies, and even systemic interventions may be necessary for the effective management of ocular allergies, tailored according to symptom severity. CONCLUSION: Ocular allergy is frequently encountered by allergists and eye-care specialists, and despite progressively increasing incidence, it often remains underdiagnosed and, hence, untreated.

Ocular surface pathogenesis associated with precocious eyelid opening and necrotic autologous tissue in mouse with disruption of Prickle 1 gene.

Ocular surface disease is one major type of eye diseases. Different etiologies trigger distinct pathological responses of the ocular surface. We previously reported that genetically engineered mice with ablation of Prickle 1 manifested precocious eyelid opening with ensuing cornea dysplasia. The current study aimed to characterize the molecular traits and the direct cause of ocular pathology associated with precocious eyelid opening in the Prickle 1 mutant mouse. Prickle 1 mutant mice exhibited a slew of ocular surface pathology including cell proliferation, cell fate transformation and inflammatory infiltration coinciding with the timing of the precocious eyelid opening. Forced eyelid opening in wild type mice did not induce cornea pathology comparable to that of the Prickle 1 mutants. Necrotic tissue debris was found associated with the lesioned cornea. RNAseq analysis of the mutant cornea revealed an expression profile shared by a range of dermatological diseases involving immune responses and cancer. Taken together, the data suggest that the necrotic eyelid debris plays an important role in ocular pathogenesis of the Prickle 1 mutant mouse, which may represent a type of non-infectious keratoconjunctivitis caused by damaged autologous tissues. Additionally, Prickle 1 mutant cornea pathogenesis may offer molecular insights into other types of epithelial pathogenesis.

Inflamed Obstructive Meibomian Gland Dysfunction Causes Ocular Surface Inflammation.

Meibomian gland dysfunction (MGD) is one of the primary causes of evaporative dry eye. Stagnation of meibum induces an unstable tear film, thus resulting in shortened tear film breakup time and superficial punctate keratopathy (SPK) in the lower cornea and punctate staining of lower bulbar conjunctiva. MGD is sometimes accompanied with inflammation (termed "meibomitis") via the proliferation of bacteria in the meibomian gland and eyelash area. Meibomitis is strongly related to ocular surface inflammation such as corneal cellular infiltrates and neovascularization, SPK, and conjunctivitis. It is difficult to differentiate SPK caused by dry eye from that caused by meibomitis. When clinicians are unaware of the existence of meibomitis, and only aware of SPK on the cornea, they often try to treat SPK as it is caused by dry eye using dry eye-specific eyedrops or even using punctual plugs when conservative therapy is ineffective. However, even when intensive dry eye therapy is applied, it may be unsuccessful until SPK caused by meibomitis is recognized and treated with systemic antimicrobial agents. Hence, the tear secreting glands, including the meibomian glands, and the ocular surface should be clinically considered as one unit (i.e., the meibomian gland and ocular surface [MOS]) when considering the pathophysiology and treatment of ocular surface inflammatory diseases (i.e., corneal epithelial damage). Following this clinical pathway, a treatment focusing on meibomian gland inflammation may be a more reasonable approach for meibomitis-related or associated keratoconjunctivitis to more effectively treat this ocular surface disease.

Potential Role of Oxidative Stress in Ocular Surface Inflammation and Dry Eye Disease.

Reactive oxygen species (ROS) are produced as a by-product during the mitochondrial respiration of the oxygen and potentially able to damage the tissues. Oxidative stress occurs as a result of the disruption of the balance between the anti-oxidant system and the pro-oxidant system found in cells. It has been accepted that overexpression of ROS can be induced in the ocular surface as a result of many acute and chronic diseases and even in normal aging. Recent studies demonstrated that oxidative stress damages the ocular surface and plays an important role in the mechanism of dry eye disease. There is a need to investigate the therapeutic modalities employing topical/systemic use of antioxidants in dry eye disease. This review will summarize the recent studies showing the important relationship between oxidative stress and dry eye disease.

Topical Tacrolimus 0.03% for Maintenance Therapy in Steroid-Dependent, Recurrent Phlyctenular Keratoconjunctivitis.

PURPOSE: To evaluate the efficacy of topical tacrolimus 0.03% as steroid-free maintenance therapy in young patients with severe, recurrent phlyctenular keratoconjunctivitis (PKC). METHODS: The medical records of 6 eyes of 5 patients (4 children and 1 young adult) with recurrent, steroid-dependent PKC were reviewed. The patients were treated with combined application of topical steroids and tacrolimus 0.03% in the active phase and maintained on topical tacrolimus alone after remission. RESULTS: The clinical signs, symptoms, and visual acuities resolved in all patients after 25.2 ± 16.9 days of combined treatment with steroids and tacrolimus. After disease remission, the patients were maintained on topical tacrolimus 0.03% once daily alone for 8.4 ± 4.7 months, and no recurrence occurred during 10.6 ± 1.9 months of follow-up. Tacrolimus was successfully discontinued in 2 patients without further recurrence. There were no ocular side effects related to the use of topical tacrolimus. CONCLUSIONS: Topical tacrolimus 0.03% was effective in maintaining long-term remission in patients with recurrent, steroid-dependent PKC.

Toxic Keratoconjunctivitis.

Toxic keratoconjunctivitis (TK) is an underrecognized complication of ophthalmic drug use and various environmental or occupational exposures. A detailed history and clinical examination are important to identify the offending agent(s). Common drug-related causes of TK include preservatives in ophthalmic medications, topical antimicrobials, and topical anesthetics. Alternatives to benzalkonium chloride as well as preservative-free formulations should be considered in patients requiring long-term topical medication. More advanced cases of TK may require preservative-free topical steroids and/or antibiotics, and occasionally surgical intervention. Early recognition and appropriate management of TK may help prevent permanent ocular and visual damage.

Changes in Higher-Order Aberrations After Phototherapeutic Keratectomy for Subepithelial Corneal Infiltrates After Epidemic Keratoconjunctivitis.

PURPOSE: To investigate how corneal aberrations change after phototherapeutic keratectomy (PTK) for subepithelial infiltrates after adenoviral keratoconjunctivitis. METHODS: The records of patients who underwent transepithelial PTK for subepithelial infiltrates were retrospectively reviewed. Preoperative best-corrected visual acuity (VA) and the results of slit-lamp biomicroscopy examinations were recorded. The PTK procedure was performed under topical anesthesia with an Amaris excimer laser. Patients' manifest refraction values, topographical examination results, and corneal aberrations before and after surgery were analyzed. RESULTS: Twenty-four eyes of 16 women (84.3%) and 3 men (15.7%) were treated. The mean follow-up time was 6.0 ± 2.5 (range: 3-12) months, and the mean ablation depth was 82.3 ± 1.0 (range: 80-88) µm. Postoperative median best-corrected VA increased from 0.6 (range: 0.4-1.0) logarithm of the minimum angle of resolution to 0.2 (range: 0.1-0.5) logarithm of the minimum angle of resolution (P = 0.048), coma decreased from 0.56 (range: 0.29-0.37) to 0.44 (range: 0.07-0.74), secondary astigmatism decreased from 0.45 (range: 0.12-1.9) to 0.17 (range: 0.03-0.49), and total higher-order aberrations decreased from 1.24 (range: 0.61-6.74) to 0.9 (range: 0.33-1.64) (P = 0.008, 0.0032, and 0.018, respectively). CONCLUSIONS: PTK is an effective method for treating corneal opacity after epidemic keratoconjunctivitis, which yields significant improvements in both VA and visual quality.

Efficacy and safety of a cationic emulsion in the treatment of moderate to severe dry eye disease: a randomized controlled study.

PURPOSE: To evaluate the efficacy and safety of a preservative-free cationic emulsion (CE) with a 0.18% hyaluronate sodium (HS) solution in patients with moderate to severe dry eye disease (DED) with keratitis or keratoconjunctivitis. METHODS: Eighty-five patients were randomized (1:1) in this multicenter, prospective, reference-controlled, parallel-group, investigator-masked study to receive CE (n = 44) or HS (n = 41). Clinical signs and symptoms were assessed over 3 months. The primary efficacy endpoint was noninferiority of CE to HS in change from baseline of ocular surface staining (OSS) score at 1 month. RESULTS: In the per protocol (PP) set and full analysis set (FAS), CE showed a similar and noninferior (p<0.0001) improvement in OSS scores compared with HS at 1 month (PP: -2.5 ± 1.3 vs -1.9 ± 1.6; FAS: -2.2 ± 1.5 vs -2.0 ± 1.8 for CE vs HS). Other clinical signs of DED similarly improved in both groups. In the FAS, global symptoms score of ocular discomfort was significantly better with CE compared with HS at 1 month (-14.8 ± 17.3 vs -7.6 ± 14.2; p = 0.0469), including greater alleviation of itching (-14.8 ± 21.2 vs -1.7 ± 19.7; p = 0.0100) and eye dryness (-21.9 ± 28.3 vs -8.4 ± 21.4; p = 0.0016). Similar trends were observed at 3 months for itching and eye dryness. Investigator global efficacy assessment and quality of life scores for eye pain and driving favored CE at 3 months. Incidence of adverse events was low in both treatment groups. CONCLUSIONS: CE was similar to HS with regards to safety and efficacy for objective signs but was superior to HS in improving DED symptoms in patients with moderate to severe DED.

Blepharokeratoconjunctivitis in childhood: corneal involvement and visual outcome.

PURPOSE: The main objective of this study is to describe the prevalence, degree and risk of corneal involvement, and visual impact in a pediatric population with blepharokeratoconjunctivitis (BKC). METHODS: Retrospective, observational, case-control study. Clinical records of patients ≤16 years old with BKC seen between 2006 and 2012 were reviewed. The prevalence and relative risk of corneal involvement was evaluated between patients with and without corneal affection through a univariate and multivariate analysis with logistic regression. Visual acuity at presentation and at last follow-up visit was also analyzed. RESULTS: One hundred and fourteen children with BKC, with a male-to-female ratio of 1 : 1 and a mean age at diagnosis of 9.13 years. The mean follow-up time was 26.4 (±25) months. Corneal involvement was present in 39.5% of patients, varying from superficial punctate keratitis to perforation. Corneal changes were not seen in children under 4 years old. The risk of corneal affection was greater in patients with photophobia, hordeolum, female gender and asymmetric disease (OR of 2.69, 11.6, 2.35 and 2.77, respectively). The mean best-corrected visual acuity at presentation was 0.20 (corneal affected group), compared to 0.11 (unaffected group; P=0.02). CONCLUSIONS: Our study showed an older age at time of diagnosis and a worse visual outcome in patients with BKC and corneal disease compared with previous reports. Early diagnosis and detection of risk factors for corneal involvement, as well as adequate treatment, is mandatory to prevent serious long-term visual repercussions in children with BKC.

Involvement of corneal lymphangiogenesis in a mouse model of allergic eye disease.

PURPOSE: The contribution of lymphangiogenesis (LA) to allergy has received considerable attention and therapeutic inhibition of this process via targeting VEGF has been considered. Likewise, certain inflammatory settings affecting the ocular mucosa can trigger pathogenic LA in the naturally avascular cornea. Chronic inflammation in allergic eye disease (AED) impacts the conjunctiva and cornea, leading to sight threatening conditions. However, whether corneal LA is involved is completely unknown. We addressed this using a validated mouse model of AED. METHODS: Allergic eye disease was induced by ovalbumin (OVA) immunization and chronic OVA exposure. Confocal microscopy of LYVE-1-stained cornea allowed evaluation of corneal LA, and qRT-PCR was used to evaluate expression of VEGF-C, -D, and -R3 in these mice. Administration of VEGF receptor (R) inhibitor was incorporated to inhibit corneal LA in AED. Immune responses were evaluated by in vitro OVA recall responses of T cells, and IgE levels in the serum. RESULTS: Confocal microscopy of LYVE-1-stained cornea revealed the distinct presence of corneal LA in AED, and corroborated by increased corneal expression of VEGF-C, -D, and -R3. Importantly, prevention of corneal LA in AED via VEGFR inhibition was associated with decreased T helper two responses and IgE production. Furthermore, VEGFR inhibition led a significant reduction in clinical signs of AED. CONCLUSIONS: Collectively, these data reveal that there is a distinct involvement of corneal LA in AED. Furthermore, VEGFR inhibition prevents corneal LA and consequent immune responses in AED.

Evaluation of the impact of persistent subepithelial corneal infiltrations on the visual performance and corneal optical quality after epidemic keratoconjunctivitis.

PURPOSE: Aim was to measure the effect of persistent subepithelial corneal infiltrates (SEIs) after epidemic keratoconjunctivitis (EKC) on visual performance and corneal optical quality. METHODS: We examined 53 patients divided into two groups. Patients with previous EKC constituted the study group (Group 1, n: 27). Healthy age matched subjects constituted the control group (Group 2, n: 26). Study group was subdivided into eyes with SEI (Group 1A, 40 eyes) and healthy fellow eyes (Group 1B, 14 eyes). Patients were submitted to a complete examination including high- and low-contrast visual acuities (HCVA, LCVA), corneal topography and aberrometry. RESULTS: The mean interval between epidemic conjunctivitis and examination was 7.25 ± 5.63 months. Mean number of corneal infiltrates was 17.30 ± 14.38. The mean HCVA and LCVA were significantly lower in the eyes with SEI than fellow eyes and control group (p = 0.001). LCVA value was also worse in the fellow eyes when compared to control (p = 0.048). Corneal topography values were significantly higher in the eyes with SEI from both fellow eyes and control group. During corneal aberrometry, the mean root mean square value of spheric aberration, irregular astigmatism and total aberration were significantly higher in SEI group when compared to fellow eyes and control group (p < 0.05). Total aberrations were higher than control subjects in the fellow eyes. Trefoil aberration was higher in SEI group only when compared to control subjects, while there was no significant difference in coma aberration values between the groups (p > 0.05). CONCLUSION: Results of this study suggested that visual performance is compromised in patients with EKC by aberrations and changes in topographic variables.

Oral steroid therapy as an adjuvant treatment for severe epidemic keratoconjunctivitis in patients younger than 3 years.

PURPOSE: To evaluate the therapeutic effect of oral steroids given to patients younger than 3 years with epidemic keratoconjunctivitis (EKC) accompanied by severe eyelid edema and inflammatory ptosis, in whom eye drops were not feasible. METHODS: This study included 9 patients treated for EKC in local clinics whose condition failed to improve due to severe eyelid swelling together with difficulties in application of eye drops and pseudomembrane removal. We analyzed the extent of eyelid swelling, corneal damage, follicles, chemosis, and pseudomembrane formation in these patients before and after oral corticosteroid therapy in collaboration with the pediatrics department. RESULTS: After a mean of 1.8 ± 0.7 days of oral steroid treatment, eyelid edema, corneal damage, conjunctival injection, follicles, and chemosis improved in all patients. CONCLUSIONS: Oral steroids are an effective adjuvant treatment for EKC in patients younger than 3 years in whom eye drops could not be administered frequently due to severe eyelid edema.

Sub-tenon triamcinolone acetonide injections for topical medication intolerance in chronic blepharokeratoconjunctivitis.

PURPOSE: To report the efficacy of sub-Tenon triamcinolone acetonide (TA) injections for chronic blepharokeratoconjunctivitis (BKC) in 2 patients who were intolerant to topical therapies. METHODS: In this retrospective observational case series, the records of 2 patients with chronic BKC who received sub-Tenon TA injections were reviewed. RESULTS: Both patients, a 4-year-old girl and a 21-year-old developmentally delayed man, were managed successfully with sub-Tenon TA injections. The treatment resulted in resolution of symptoms, diminished corneal haze, reduced conjunctival injection, and improved visual acuity without complications. CONCLUSIONS: This case series illustrates the potential benefit of using sub-Tenon TA injections for chronic BKC in patients who are intolerant to topical corticosteroid therapy. Therefore, sub-Tenon TA injections may be considered for patients with vision-threatening BKC and nonadherence to topical therapies.

The efficacy of corneal debridement in the treatment of microsporidial keratoconjunctivitis: a prospective randomized clinical trial.

PURPOSE: To evaluate the efficacy of corneal debridement in the treatment of clinically diagnosed cases of microsporidial keratoconjunctivitis. DESIGN: Prospective, double-masked randomized clinical trial. METHODS: Patients with clinical features such as multifocal, coarse, raised, punctate, round to oval epithelial lesions in the cornea in slit-lamp examination with mild to moderate conjunctival congestion, suggestive of microsporidial superficial keratoconjunctivitis, were included in the prospective study. All patients were randomized into 2 groups. Group 1 patients underwent debridement with the help of a sterile #15 blade on a Bard-Parker handle, whereas only conjunctival swabs were taken from Group 2 patients. All patients were treated with ocular lubricants. RESULTS: One hundred and twenty patients with clinical features suggestive of microsporidial superficial keratoconjunctivitis were included in the study. The mean age was 34.3 ± 13.6 years (Group 1) and 35.8 ± 16.2 years (Group 2) (P = .59). The mean duration of symptoms was 6.8 ± 3.9 days (Group 1) and 7.2 ± 4.6 days (Group 2) (P = .61). Baseline characteristics showed no difference between the 2 groups. The primary outcome was the time from the presentation to complete resolution (ie, absence of corneal lesions) of the clinical signs and symptoms. The secondary outcomes were final visual acuity and residual corneal side effects and/or scarring, if any. The mean resolution time of the corneal lesions was 5.7 ± 4.0 days (Group 1) and 5.9 ± 3.9 days (Group 2) (P = .83). There was no significant difference in final visual outcome in the 2 groups. No serious side effects were observed. CONCLUSION: Debridement does not have any significant advantage in terms of resolution of the corneal lesions and final visual outcome in cases of microsporidial keratoconjunctivitis.

Atopic keratoconjunctivitis: A review.

Atopic keratoconjunctivitis is a chronic noninfectious inflammatory condition and is one of the most severe ophthalmic complications associated with atopic dermatitis. It requires prompt and effective treatment to prevent permanent vision loss. Complications of atopic keratoconjunctivitis include cataracts, keratoconus, infectious keratitis, blepharitis, tear dysfunction, and steroid-induced glaucoma. All treatment for atopic keratoconjunctivitis should be managed in conjunction with an ophthalmologist, and immediate referral is indicated when there is moderate to severe irritation, increased redness, discharge, or any visual symptoms. Treatment options include a combination of mast cell inhibitors, antihistamines, corticosteroids, and calcineurin inhibitors.

Changes in sensory activity of ocular surface sensory nerves during allergic keratoconjunctivitis.

Peripheral neural mechanisms underlying the sensations of irritation, discomfort, and itch accompanying the eye allergic response have not been hitherto analyzed. We explored this question recording the changes in the electrical activity of corneoconjunctival sensory nerve fibers of the guinea pig after an ocular allergic challenge. Sensitization was produced by i.p. ovalbumin followed by repeated application in the eye of 10% ovalbumin on days 14 to 18. Blinking and tearing rate were measured. Spontaneous and stimulus-evoked (mechanical, thermal, chemical) impulse activity was recorded from mechanonociceptor, polymodal nociceptor and cold corneoscleral sensory afferent fibers. After a single (day 14) or repeated daily exposures to the allergen during the following 3 to 4days, tearing and blinking rate increased significantly. Also, sensitization was observed in mechanonociceptors (transient reduction of mechanical threshold only on day 14) and in polymodal nociceptors (sustained enhancement of the impulse response to acidic stimulation). In contrast, cold thermoreceptors showed a significant decrease in basal ongoing activity and in the response to cooling. Treatment with the TRPV1 and TRPA1 blockers capsazepine and HC-030031 reversed the augmented blinking. Only capsazepine attenuated tearing rate increase and sensitization of the polymodal nociceptors response to CO2. Capsazepine also prevented the decrease in cold thermoreceptor activity caused by the allergic challenge. We conclude that changes in nerve impulse activity accompanying the ocular allergic response, primarily mediated by activation of nociceptor's TRPV1 and to a lesser degree by activation of TRPA1 channels, explain the eye discomfort sensations accompanying allergic episodes.

Corneal sensitivity may decrease in adenoviral epidemic keratoconjunctivitis--a confocal microscopic study.

OBJECTIVES: To report a new clinical finding, decreased corneal sensitivity, in epidemic keratoconjunctivitis and to evaluate this sign with corneal confocal microscopy. METHODS: Forty-one eyes of 28 patients who developed corneal infiltrates after an outbreak of epidemic keratoconjunctivitis were included in the study. Clinical and confocal microscopic findings are described. RESULTS: In this outbreak of 72 patients, 28 (38.9%) developed corneal infiltrates. The corneal involvement was unilateral in 15 patients (53.6%) and bilateral in 13 patients (46.4%). Corneal sensitivities were measured in 35 eyes of 24 patients and found to be decreased in 26 eyes (74.3%). Decreased corneal sensation was a feature of mainly stage 2 (7 eyes) and stage 3 (11 eyes) keratitis. Corneal sensitivity returned to normal levels in all eyes in a mean of 8.5 days. The main confocal microscopic features during the period of decreased corneal sensitivity were morphologic changes in the infected epithelial cells, extracellular bright microdeposits, infiltration with round inflammatory cells and dendritic cells, increased brightness in the extracellular matrix and the stroma surrounding the corneal nerves, and increased keratocyte activity. The intensity of the inflammatory reaction in the extracellular space and corneal stroma and the reflectivity of the corneal nerves had subsided by the second confocal measurements. CONCLUSION: There may be a transient decrease in the corneal sensitivity during the course of epidemic keratoconjunctivitis. Confocal microscopy can help to evaluate the changes in the cornea during this period. Future studies are needed to understand the nature of this clinical finding.

Indications and outcomes of amniotic membrane transplantation in the management of acute stevens-johnson syndrome and toxic epidermal necrolysis: a case-control study.

PURPOSE: To evaluate the indications and outcomes of amniotic membrane transplantation (AMT) performed within the first 2 weeks of presentation in the management of patients with acute Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). METHODS: A retrospective chart review from January 1998 to May 2011 identified 128 SJS/TEN patients admitted to Loyola University Medical Center Burn intensive care unit. The degree of initial ocular surface inflammation was graded as mild, moderate, or severe within the first 2 weeks of admission. Patients were managed either medically or with amniotic membrane (AM). Outcomes were graded as good [best-corrected visual acuity (BCVA)>20/40], fair (BCVA 20/40 to 20/200 or with ocular surface discomfort, requiring contact lens or reconstructive surgeries), or poor (BCVA<20/200). RESULTS: Of the 182 eyes (91 patients) with documented inpatient eye examinations, 108 eyes (59.4%) had mild or no initial ocular involvement, 37 eyes (20.3%) had moderate, and 37 eyes (20.3%) had severe inflammation. Of the 29 patients (58 eyes) with greater than 1 month of follow-up, 17 patients (33 eyes) were treated with medical management and 13 patients (25 eyes) were treated with early AM. One of the 23 eyes with moderate or severe presentation treated with early AMT (4.3%) resulted in a poor outcome within 3 months compared with 8 of 23 eyes (34.8%) that were medically managed (P=0.022). CONCLUSIONS: We present the first case-control study of the use of AM in the management of acute SJS/TEN. Early use of AMT prevents severe vision loss in SJS/TEN patients with initial moderate or severe ocular surface inflammation.

Omalizumab. An option in vernal keratoconjunctivitis?

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