Purpose:

To report a patient with vernal conjunctivitis who had recurrent shield ulcer complicated by bacterial keratitis.

Methods:

Case report. A 10 years old boy who had history of ocular itching and photophobia for two years was presented with a complaint of pain and visual loss in the left eye. His visual acuity was 10/10 in the right eye and hand movement in the left eye. Slit-lamp examination revealed excess discharge of mucus and cobblestone papillae on the superior tarsal conjunctiva were observed in both eyes. In the left eye,there was an oval scar induced by the previous shield ulcer on the upper half of the cornea and a plaque-shaped ulcer next to its lower border.The base area and margins of the ulcer were infiltrated.The cornea was grossly edematous and there was hypopyon of 4 mm. Considering the clinical diagnosis of shield ulcer complicated by bacterial keratitis,the patient was treated with fortified vancomycin,ceftazidime, 0.5%cyclosporine, cyclopentolate and systemic antihistaminic.The symptoms resolved completely within 5 weeks and visual acuity increased to 7/10. The patient applied again with similar complaints 4 months later. In the left eye,there was a new ulcer with infiltrated margins and base area near the old scars and excess stromal edema. The visual acuity was counting fingers at 0.5 meter. After the treatment with fortified cefazolin,gentamycin, 0.5%cyclosporine, cyclopentolate and systemic antihistaminic, the ulcer healed and visual acuity improved to 4/10.

Conclusion:

Although secondary bacterial keratitis associated with shield ulcer is uncommon in patients with vernal keratoconjunctivitis,it is a vision-threatening complication. In the treatment,it is important that the inflammation caused by vernal conjunctivitis must be suppressed simultaneously with effective antibiotics therapy. Topical cyclosporine, shown to be effective in the treatment of vernal keratoconjunctivitis may be a reliable and effective adjunctive in patents with secondary bacterial keratitis.

Keywords: vernal keratoconjunctivitis, shield ulcer, bacterial keratitis, topical cyclosporin