Long Term Outcomes of Surgical Excision of Giant Papillae with Mitomycin C and Amniotic Membrane Transplantation in the Treatment of Refractory Palpebral Vernal Keratoconjunctivitis.

Background and Objectives: To report the long-term outcomes of patients with refractory Vernal Keratoconjunctivitis (VKC) who underwent surgical excision of giant papillae (GP) with mitomycin C (MMC) 0.02% and amniotic membrane transplantation (AMT). Materials and Methods: This is a retrospective interventional single-center case series including five eyes of four patients who had refractory, symptomatic VKC with GP, along with corneal shield ulcers and/or punctate epithelial erosions. They underwent surgical excision of GP with MMC 0.02% alone (1 eye) or with MMC 0.02% and AMT (4 eyes). Their long-term visual and surgical outcomes were studied. Results: All subjects were male with bilateral involvement and mean age of presentation 9.8 years. The surgery was uneventful in all cases. Amongst the four eyes which underwent MMC with AMT, only one eye demonstrated papillary regrowth requiring repeat surgery. Postoperative follow-up ranged from 59 to 77 months (median 66 months). Four patients had the best corrected visual acuity (BCVA) >/= 6/9.5. One patient had BCVA 6/15 at the final follow-up due to the presence of anterior corneal stromal scar and poor ocular surface. Conclusions: Surgical excision of GP in combination with MMC and AMT, in refractory VKC, is a good treatment option with better clinical outcomes over a longer follow-up.

Mini-monoka stenting for patients with perennial allergic conjunctivitis.

Purpose: To assess the effectiveness of mini-monoka (MM) stenting in treating patients with perennial allergic conjunctivitis (PAC) and punctal stenosis. Methods: A retrospective case analysis was performed on 20 patients (40 eyes) who suffered from PAC with punctal stenosis who underwent MM (FCI Ophthalmics, Pembroke, MA, USA) stenting. Results: Nineteen patients (95%) were females, with an age range of 19-66 years (average 40.6 ± 25.4 years). All 20 patients (100% of eyes) had signs of PAC and punctal stenosis. All 20 patients (40 eyes) had received previous topical treatment including steroids. Nineteen patients (95% of eyes) had significant improvement in their allergy symptoms (tearing and conjunctival inflammation) following MM stenting. Conclusions: Stenosis of the punctum may play a role in the relapsing symptoms in PAC. MM stenting is a simple, safe, effective, and relatively non-invasive treatment option for the management of PAC in the presence of punctal stenosis.

[Eye lid hygiene in chronic allergic blepharoconjunctivitis patients before laser refractive surgery]. / Gigiena vek v podgotovke k lazernoi refraktsionnoi khirurgii.

AIM: To evaluate the effectiveness of eyelid hygiene in patients with chronic allergic blepharoconjunctivitis (ABC) as a part of their preparation for laser refractive surgery. MATERIAL AND METHODS: The study involved 32 patients (12 males and 20 females aged 25-42 years) with refractive errors, namely, compound myopic astigmatism (23 patients) and hyperopic astigmatism (9 patients) suffering from chronic ABC and secondary dry eye syndrome (DES). All the patients initially received a standard treatment for ABC and DES, that is olopatodin hydrochloride instillations - 1 mg/ml 2 times daily, preservative-free hyaluronic acid preparation - 1 mg/ml 3 times daily, and polyacrylic acid and dexpanthenol gel at night for one month. The scheme, however, appeared not effective enough. Hence, the patients were prescribed eyelid hygiene (Blepharolotion or Blepharosalfetka plus Blepharogel-1 2 times daily) to relive meibomian gland dysfunction (MGD). They also underwent a conventional ophthalmic examination, allergy tests, evaluation of ABC and DES signs and symptoms, tear film break-up time test, Schirmer's test, meibomian glands evaluation, optical coherence tomography with meniscometry, xerosis index evaluation, and lissamine green staining for lid wiper epitheliopathy. RESULTS: At the beginning of the study signs and symptoms of MGD-associated DES were predominant in all patients. Chronic ABC signs were mild. In 2-3 months, meibomian gland function and tear film break-up time improved significantly in most patients, while xerosis index decreased and lid wiper epitheliopathy resolved. Laser refractive surgery (LASIK) was performed in 81.25% of patients, all of whom were satisfied with the results. CONCLUSION: Inclusion of eyelid hygiene into preoperative management of patients with chronic ABC and DES allows to achieve optimum conditions for laser refractive surgery in most cases.

Surgical management and immunohistochemical study of corneal plaques in vernal keratoconjunctivitis.

Two children with shield ulcer in vernal keratoconjunctivitis unresponsive to steroid therapy received plaque removal by superficial keratectomy, followed by amniotic membrane transplantation (AMT). Hematoxylin and eosin staining of the excised corneal specimen revealed a thick layer of eosinophilic material attached to the Bowman's layer. These deposits were positive for eosinophil granule major basic protein, as confirmed by an immunohistochemical study. The shield ulcer healed after the amniotic membrane was removed. No recurrent corneal plaque developed, although corneal opacity complicated in both cases. Lamellar keratectomy with AMT offers an effective management by removing the cytotoxic plaques and protecting the denuded stroma from deposition of inflammatory debris.

Surgical debridement plus topical cyclosporine A in the treatment of vernal shield ulcers.

Vernal keratoconjunctivitis (VKC) is a severe chronic bilateral inflammation of the ocular surface characterized by seasonal exacerbations. Long-term prognosis is generally good; however, 6% develop sequelae responsible for permanent visual impairment. Corneal involvement is almost always present, consisting of punctate keratitis, shield ulcers (3-11%) and late corneal neovascularization. In recent years, topical cyclosporine A preparations at 2% in oil or at 1% in polyvinyl alcohol, have been successfully proposed for long term VKC treatments. It has been previously proven that medical treatment is not always sufficient, especially when it is employed to treat shield ulcer plaques. In such conditions, surgery may be effective for avoiding long term complications such as amblyopia, strabismus, infections and corneal perforation. In this paper, we show the efficacy of surgical debridement by means of simple scraping associated with topical cyclosporine treatment for the management of vernal shield ulcers complicated with plaques.

Allergic conjunctivitis increases the likelihood of undergoing eyelid incision surgery in pediatric and adolescent patients.

The global prevalence of allergic diseases has increased dramatically in recent decades. From a global health perspective, they have been considered as a major chronic disease, and the related social burden has also been increasing worldwide. In line with this trend, we investigated the likelihood of undergoing incision surgery for eyelid inflammatory masses in pediatric and adolescent patients with allergic conjunctivitis (AC). The prevalence of AC and incision surgery showed a similar pattern of bimodal peaks during the spring and autumn of South Korea, reflecting the peak allergic seasons. The likelihood of undergoing incision surgery in patients with AC was 4.27 times higher than that of patients without AC and the likelihood of undergoing incision surgery was higher in every age group in the AC cohort than in the non-AC cohort. There was no significant difference between age groups and sexes. In the AC cohort for sub-analysis, the likelihood of undergoing incision surgery was 2.34 times higher in patients who used steroids than those who did not. These findings can suggest that proper management and education can be required for the likelihood of undergoing incision surgery due to eyelid inflammation mass in pediatric and adolescent patients with AC. Furthermore, greater attention should be paid to patients using steroids due to severe AC as they are more likely to undergo incision surgery.

Boston type 1 keratoprosthesis for severe blinding vernal keratoconjunctivitis and Mooren's ulcer.

Indications for the Boston keratoprosthesis differ throughout the world depending on the prevailing regional causes of end-stage corneal disease. We report the short term anatomical and functional outcomes of the Boston type 1 keratoprosthesis for severe bilaterally blinding vernal keratoconjunctivitis and Mooren's ulcer. A retrospective chart review was conducted of 2 patients who underwent several unsuccessful ocular surface reconstruction procedures before Boston type 1 keratoprosthesis implantation. The anatomical and visual outcomes of the Boston type 1 keratoprosthesis at 1 year of follow-up were assessed clinically and by anterior segment optical coherence tomography imaging. The keratoprosthesis was retained in both the eyes at 1 year postoperatively with a best-corrected visual acuity of 20/30 in both patients. To our knowledge this is the first report of successful Boston keratoprosthesis implantation for these two unusual indications.

"Doughnut" Amniotic Membrane Transplantation With Penetrating Keratoplasty for Vernal Keratoconjunctivitis With Limbal Stem Cell Disease.

PURPOSE: Severe vernal keratoconjunctivitis (VKC) can cause ocular surface disease including partial or complete limbal stem cell deficiency (LSCD), especially in early-onset and severe limbal form of VKC. We report a novel technique of doughnut amniotic membrane transplantation (AMT) along with penetrating keratoplasty (PK) for management of partial LSCD and corneal scarring in a case of severe VKC. METHODS: Case report. RESULTS: A 17-year-old boy, with onset of disease at 8 years of age, and development of partial LSCD and corneal scarring over a period of 9 years despite therapy, presented with profound visual loss due to dense bilateral corneal scarring. After the active allergy subsided, he underwent modified AMT (doughnut AMT) with simultaneous PK in his left eye. Histopathology of the excised button revealed conjunctival phenotype and dense corneal scarring up to the posterior stroma. At 1-year follow up, his best spectacle-corrected visual acuity was maintained at 20/30 in the operated eye, the graft was clear, and the ocular surface was stable. CONCLUSIONS: Severe VKC can cause ocular surface disease including LSCD with corneal scarring, especially in early-onset limbal form of VKC. The modified technique of AMT (doughnut AMT) along with PK can successfully visually rehabilitate and address partial LSCD in such patients.

Allergic airway hyperreactivity increases the risk for corneal allograft rejection.

Corneal allografts transplanted into hosts with allergic conjunctivitis experience an increased incidence and swifter tempo of immune rejection compared to corneal allografts transplanted to nonallergic hosts. Previous findings suggested that increased risk for rejection was not a local effect produced by an inflamed eye, but was due to perturbation of the systemic immune responses to alloantigens on the corneal allograft. We tested the hypothesis that another allergic disease, airway hyperreactivity (AHR), would also increase the risk for corneal allograft rejection. Induction of AHR with either ovalbumin (OVA) or short ragweed (SRW) extract prior to keratoplasty resulted in a steep increase in the speed and incidence of corneal allograft rejection. Delayed-type hypersensitivity (DTH) responses to corneal alloantigens were closely associated with corneal allograft rejection. However, the deleterious effect of AHR on corneal allograft survival was not reflected in a heightened magnitude of allospecific DTH, cytotoxic T lymphocyte and lymphoproliferative responses to the alloantigens on the corneal allograft. Unlike Th2-based immediate hypersensitivity, CD8+ T-cell-based contact hypersensitivity to oxazolone did not increase the risk for corneal allograft rejection. Thus, Th2-based allergic diseases significantly reduce the immune privilege of the corneal allograft and represent important risk factors for consideration in the atopic patient.

Outcomes and Rationale of Excision and Mucous Membrane Grafting in Palpebral Vernal Keratoconjunctivitis.

PURPOSE: To report outcomes of mucous membrane grafting (MMG) for refractory giant papillae in vernal keratoconjunctivitis. METHODS: Eleven eyes of 6 patients having giant papillae and recurrent shield ulcers refractory to topical medications, cryotherapy, and supratarsal steroid injections and shave excision of papillae underwent surgical resection of the giant papillae with MMG. Average occurrence of shield ulcers was twice per eye per year before the procedure with 50% of eyes having steroid-induced cataract and glaucoma. RESULTS: No recurrence of the shield ulcer in any eye was observed over a mean follow-up period of 38.2 (range 9-106) months. The papillae recurred beyond the graft junction in one eye. CONCLUSIONS: Surgical excision of refractory giant papillae followed by MMG does have its advantages in reducing their corneal complications, and it should be considered early in the management of exuberant refractory giant papillae.

[Preliminary report of surgical treatment of vernal keratoconjunctivitis with giant papillae].

OBJECTIVE: To evaluate the efficacy and safety of excision and cryotherapy combine with amniotic membrane transplantation (AMT) for the treatment of vernal keratoconjunctivitis (VKC) with giant papillae (GP). METHODS: Eight patients (16 eyes) with VKC, characterized by GP on the upper tarsal conjunctiva, refractory to medical treatment, underwent excision and cryotherapy associated with AMT. The follow up period ranged 3-22 months. RESULTS: Corneal shield ulcers and superficial punctuate keratitis healed during the first week after the surgery and did not recur. Fourteen eyes were symptom free and without GP one month after surgery. No ectropion, trichiasis and other complications were noted. The blood vessels of upper tarsal conjunctiva could not be seen clearly, a small amount of conjunctival scar was observed. Recurrence of GP was observed in 2 eyes, with reduced area and lessened irritation symptom as compared with preoperative status. Among them, one eye was treated by cyclosporine eyedrops with improvement. The other eye did not improve, and underwent secondary surgery (a cotton patch soaked in fluorouracil was applied on the upper eyelid after excision and cryotherapy). Nine months after the treatment, the patient had no symptoms and GP did not recur. CONCLUSIONS: Excision and cryotherapy combine with AMT may be an effective and safe method for the treatment of refractory VKC with GP. But the candidates for surgical treatment should be chosen carefully.

Rapid healing of vernal shield ulcer after surgical debridement: A case report.

PURPOSE: This study was designed to report a patient with a vernal shield ulcer that did not respond to medical therapy but healed in 1 week after surgical debridement of the ulcer base. METHODS: Case report and literature review. RESULTS: A 12-year-old girl with a history of asthma and eczema was seen with a 5.7- x 5.7-mm corneal epithelial defect in the right eye. Her uncorrected visual acuity was 20/200 OD and 20/70 OS. Slit-lamp examination revealed giant papillae on the tarsal conjunctivae, diffuse punctate epitheliopathy, and a thick mucoid discharge in both eyes. A diagnosis of vernal keratoconjunctivitis both eyes (OU) with a shield ulcer OD was made and prednisolone 1% was started 4 times per day OD. Topical ofloxacin 0.3% 3 times per day and topical cyclosporine 0.05% every 2 hours were added OD 2 days later. On minimal improvement in the epithelial defect in 1 week, surgical debridement of the ulcer base was performed. The epithelial defect healed smoothly in 1 week with an underlying stromal scar and the uncorrected visual acuity improved to 20/70 OD at 1 month and 20/40 at 10 months. CONCLUSION: Corneal shield ulcers and plaques are rare but serious complications of vernal keratoconjunctivitis, which may be unresponsive to standard medical therapy. Surgical debridement is a fast and effective procedure yielding rapid healing of the ulcer and minimizing complications, such as infections.

Resection and cryotherapy combined with amniotic membrane transplantation for the treatment of vernal keratoconjunctivitis with giant papillae.

To evaluate the efficacy and safety of resection and cryotherapy combined with amniotic membrane transplantation (AMT) for the treatment of vernal keratoconjunctivitis (VKC) with giant papillae (GP). Eight patients (16 eyes involved) with VKC, characterized by GP on the upper tarsal conjunctiva, underwent resection and cryotherapy in combination with AMT. The follow-up lasted for 3-22 months. The results showed that corneal shield ulcers and superficial punctuate keratitis healed during the first week after surgery and did not recur. Fourteen eyes (87.5 %) were symptom-free 1 month after surgery, and no GP, ectropion, trichiasis and other complications were noted, but the blood vessels of upper tarsal conjunctiva could not be clearly seen and a little conjunctival scar was observed. Recurrence of GP was observed in 2 eyes (12.5 %), with the area being less and irritation milder as compared with those before the operation. Among the two eyes, one eye was treated by cyclosporine eyedrops with improvement, but the other eye showed no improvement after the treatment, and underwent a second surgery with a cotton patch soaked in fluorouracil applied onto the supratarsal area after resection and cryotherapy. Four months after the treatment the patient presented no symptoms and GP did not recur. It is concluded that the resection and cryotherapy combined with AMT is an effective and safe treatment for VKC with GP.

Vernal keratoconjunctivitis: culmination of management using immunosuppression, surgical and prosthetic therapy over quarter century.

A 22-year-old male patient presented in 1988 with active vernal keratoconjunctivitis. He was treated with topical mast cell stabilisers and corticosteroids. Chronic inflammation despite topical treatment necessitated oral immunosuppressants. Active disease came under control with this; however, the patient gradually developed limbal stem cell deficiency. He underwent bilateral pannus resection with amniotic membrane transplantation that resulted in improved ocular surface. In 2007, patient was found to have significant bilateral posterior subcapsular cataracts and underwent bilateral cataract surgery with intraocular lens implantation with good visual outcome. In 2016, he was provided with scleral lens prosthetic device, which further improved vision. At last follow-up, more than 25 years after his initial visit, his visual acuity was 20/25 in both eyes with a stable surface. With a comprehensive approach using immunosuppression, surgical therapy and scleral lens prosthetic device, chronic vernal keratoconjunctivitis can be well managed as illustrated in this case.

Atopic keratoconjunctivitis: long-term results of medical treatment and penetrating keratoplasty.

PURPOSE:: To evaluate the long-term outcomes of medically or surgically treated patients with atopic keratoconjunctivitis (AKC). METHODS:: Charts of 16 patients with AKC (32 eyes) observed between 1996 and 2013 were reviewed retrospectively. Outcome measures included demographic features, follow-up duration, and biomicroscopic findings at the first and most recent visits. The corrected distance visual acuity (CDVA; in decimal units) was evaluated at the initial visit and the 1-, 6-, and 12-month follow-up visits. RESULTS:: In the medically treated group (25 eyes of 15 patients), the median follow-up duration was 3 (range, 1-9) years, and the median CDVA values were 0.01 (0.001-1.0) at the first visit and 0.01 (0.001-0.8) at the most recent visit (p=0.916). In the penetrating keratoplasty (PK) group (7 eyes of 6 patients), the median follow-up duration was 7 years (range, 1-11), and the median CDVA increased from 0.01 (0.001-0.01) to 0.2 (0.001-0.7) postoperatively (p=0.043). CONCLUSION:: Whereas most AKC patients maintained a useful CDVA with medical treatment, PK may be required in some cases. Despite the frequent occurrence of complications, PK can significantly improve the CDVA.

Cultivated corneal epithelial transplantation for severe ocular surface disease in vernal keratoconjunctivitis.

PURPOSE: To report cultivated epithelial transplantation in 2 patients with vernal keratoconjunctivitis (VKC) with severe ocular surface disease. METHODS: Two patients initially diagnosed with burnt-out VKC presented with bilateral photophobia, decreased vision, and corneal neovascularization. The first patient underwent living-related conjunctival-limbal allograft in the left eye and cultivated limbal epithelial cell allotransplant in the right. The second patient underwent unsuccessful amniotic membrane transplantation (AMT) followed by autologous cultivated limbal epithelial cell transplantation in the worse eye. RESULTS: Both patients had onset of VKC in the first decade. Surgical intervention in both led to marked amelioration in symptoms and improvement in vision. In patient 1, vision improved from 20/800 (both eyes) to 20/30 in the right and 20/100 in the left eye at a follow-up of 34 months. In patient 2, it improved from 20/400 to 20/50 after the second procedure, 25 months postoperatively. Histopathology of the excised pannus revealed fibrosis and mononuclear cell infiltrates in all 3 eyes. CONCLUSIONS: Severe ocular surface disease may occur in persistent VKC, leading to marked visual loss. AMT alone may be insufficient to restore the ocular surface, and limbal epithelial cell transplantation is warranted.

Removal of giant vernal papillae by CO2 laser.

BACKGROUND: We report our experience in removing giant papillae in cases with severe vernal keratoconjunctivitis using CO2 laser. METHODS: Five cases with conjunctival giant papillae due to severe vernal keratoconjunctivitis were treated with CO2 laser. All cases were resistant to conventional treatment. In 4 eyes, there was also an associated corneal shield ulcer. RESULTS: In all 5 cases the procedure was uneventful. Retreatment was performed in only 2 cases because of recurrence of the papillae. No intra- or postoperative complications were observed. INTERPRETATION: CO2 laser seems to be a safe method for removing conjunctival giant papillae in cases with severe vernal keratoconjunctivitis. It is also a repeatable method that enables a rapid conjunctival and corneal recovery.

Penetrating keratoplasty in eyes with keratoconus and vernal keratoconjunctivitis.

PURPOSE: To determine the prognosis of penetrating keratoplasty in eyes with keratoconus and vernal keratoconjunctivitis. METHODS: The medical records of all patients with keratoconus and vernal keratoconjunctivitis who underwent penetrating keratoplasty at King Khaled Eye Specialist Hospital from January 1, 1986 to December 31, 1996 and for whom at least 24 months' follow-up is available were analyzed retrospectively. RESULTS: Of 85 (61 males, 24 females) patients, 90 eyes met the inclusion criteria. The mean follow-up was 44.7 (range, 26-144) months. At the most recent follow-up visit, 83 (92.2%) grafts were clear. The mean best corrected visual acuity was 20/40. Graft rejection episodes occurred in 12 (13.3%) eyes, with irreversible graft failure occurring in 4 (4.4%) eyes. Bacterial keratitis occurred in 6 (7.7%) eyes, 2 (2.2%) of which developed irreversible graft failure. Herpes simplex keratitis resulted in irreversible graft failure in 1 (1.1%) eye. CONCLUSION: Penetrating keratoplasty in eyes with keratoconus and vernal keratoconjunctivitis has an excellent visual outcome and a low complication rate.

A comparative evaluation of the efficacy of intraoperative mitomycin C use after the excision of cobblestone-like papillae in severe atopic and vernal keratoconjunctivitis.

OBJECTIVE: To evaluate the effect of intraoperative 0.02% mitomycin-C (MMC) use after excision of cobblestone-like papillae on preventing corneal recurrences compared with simple papillary resection. METHODS: Thirteen cases of atopic keratoconjunctivitis (AKC) and 6 cases of vernal keratoconjunctivitis (VKC) with a mean age of 12.0 +/- 3.4 years participated in this study. All patients had cobblestone-like papillae on the upper tarsal conjunctiva and corneal ulcers or erosions that were refractory to conventional treatment. Seventeen eyes received simple papillary excision. Papillary excision with intraoperative application of MMC was performed in 7 eyes: 0.02% MMC was applied for 2 minutes to the upper palpebral conjunctiva immediately after papillary excision. Recurrence of corneal lesions and regrowth of papillae were evaluated and compared retrospectively between the 2 groups. Postoperative follow-up ranged from 12 to 18 months. RESULTS: Papillary regrowth was observed in 14 out of 17 eyes (82.4%) in the simple resection group, whereas regrowth was noted in 4 out of 7 eyes (57.1%) in the MMC group (P > 0.05). The recurrence of corneal lesions was observed in 8 out of 17 eyes (47.1%) in the simple resection group (mean onset 1.5 +/- 1.7 months) compared with 1 eye with corneal recurrence 6 months after surgery in the MMC group (14.3%). The difference was statistically significant (P < 0.05). No complications related to MMC use were observed during the follow-up period. CONCLUSION: MMC-aided papillary resection may be rewarding in well-selected severe AKC and VKC cases in preventing recurrence of corneal complications, but the potential complications of MMC use would suggest caution in its consideration.