Surgical debridement of corneal shield ulcers in pediatric patients: two case reports and a review of the literature

Abstract

Background: Ocular allergy is a common disease, especially in the pediatric population, with unpleasant and longterm consequences, including corneal complications and decreased visual acuity. This study reports two cases of corneal shield ulcer due to vernal keratoconjunctivitis, with good results of surgical debridement performed after failure of long-term clinical treatment. Furthermore, this study highlights that this therapeutic approach, although less common, is efficient in treating refractory cases that cause suffering in pediatric patients. Case presentation: The first patient was a 7-year-old Caucasian boy with chronic ocular allergy, especially photophobia, who had been treated with eye drops, antihistamine, and corticosteroids for 60 days without success. Biomicroscopy of the right eye showed the presence of gelatinous limbus, giant papillae in the tarsal conjunctiva, and a shield ulcer measuring 6.0 mm vertically and 2.7 mm horizontally. Surgical debridement was performed, and the ulcer did not recur. The second patient was a 4-year-old Caucasian boy with chronic ocular allergy, especially itching and photophobia, who had been treated with eye drops for 1 year without success. Biomicroscopy of the left eye showed a shield ulcer, with a dense central corneal plaque, measuring 8 mm vertically and 3.5 mm horizontally. Surgical debridement of the ulcer was performed immediately because of the chronicity of the case and severity of the lesion, and the treatment was effective. Conclusions: The treatment of shield ulcers caused by vernal keratoconjunctivitis in the two reported cases was curative and definitive by surgical debridement in the 7-month follow-up period. Therefore, the early debridement of shield ulcers refractory to drug treatment can considerably reduce the time of disease evolution and the probability of ocular complications caused by clinical treatment or disease chronicity. However, this approach is rarely described in the literature and needs to be included in the ophthalmologist's therapeutic arsenal.

Vernal Keratoconjunctivitis: A Systematic Review

“…3 of 4 patients responded to the treatment, but the response was incomplete Low Occasi et al [ 159 ] 2017 Italy 4 8.5 To report 4 cases of VKC treated with omalizumab After a 6-month omalizumab therapy, all children experienced an improvement of ocular symptoms and signs. No relapse was observed after treatment suspension Low Callet et al [ 160 ] 2018 France 2 8.0 To describe omalizumab use in VKC and asthma patients Monthly omalizumab therapy permitted VKC and asthma control in both patients Low Westland et al [ 161 ] 2018 Netherlands 3 11.0 To describe an intense regimen of 0.05% cyclosporine for vernal shield ulcers Cyclosporine 8 times a day treatment provided quick resolution of the shield ulcers and complete re-epithelialization Low Maharana et al [ 149 ] 2021 India 11 13.7 To describe the combined topical cyclosporine (CsA) 0.1% and tacrolimus 0.03% use in VKC Combined therapy allowed an improvement in VKC signs and symptoms ( p < 0.001) High Stock et al [ 17 ] 2020 Brazil 2 5.5 To report two cases of corneal shield ulcer treated which surgical debridement In both cases, surgical debridement was curative and definitive in the 7-month follow-up period. Shield ulcer did not recur Medium Patil and Mehta [ 162 ] 2022 Singapore …”

“…In all these works, key statements are supported by adequate references. Stock et al [ 17 ] performed the best data presentation. On the other hand, the worst performance was of Takamura et al [ 24 ] and Kraus [ 18 ] (1/12 and 2/12, respectively).…”

Diagnosis, Management, and Treatment of Vernal Keratoconjunctivitis in Asia: Recommendations From the Management of Vernal Keratoconjunctivitis in Asia Expert Working Group

“…Surgical approaches can include excision of giant papillae, debridement of the corneal plaque to remove cytotoxic cells, and amniotic membrane transplantation ( 66 ). Surgical treatment, especially corneal plaque removal, may be appropriate for patients with ulcers of moderate-to-severe severity, because short-term re-epithelialization rates are higher and the number of complications is lower than that associated with medical therapy ( 66 ).…”

“…Surgical approaches can include excision of giant papillae, debridement of the corneal plaque to remove cytotoxic cells, and amniotic membrane transplantation ( 66 ). Surgical treatment, especially corneal plaque removal, may be appropriate for patients with ulcers of moderate-to-severe severity, because short-term re-epithelialization rates are higher and the number of complications is lower than that associated with medical therapy ( 66 ). Other reports suggest surgical treatment, such as giant papillae excision, may be appropriate in cases of corneal involvement and in the presence of coarse giant tarsal papillae resulting in ptosis (or mechanical pseudoptosis) ( 1 , 67 ).…”

“…Surgical approaches that focus on conjunctival cobblestone papillae, shield ulcers, corneal plaques, limbal insufficiency, and other ocular surface presentations that do not respond to medical treatment can be beneficial (63)(64)(65). Surgical approaches can include excision of giant papillae, debridement of the corneal plaque to remove cytotoxic cells, and amniotic membrane transplantation (66). Surgical treatment, especially corneal plaque removal, may be appropriate for patients with ulcers of moderate-to-severe severity, because short-term re-epithelialization rates are higher and the number of complications is lower than that associated with medical therapy (66).…”