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    Shield Ulcer

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    Allen Sally
    Shield ulcers in vernal keratoconjunctivitis can form due to two hypothesized mechanisms: the mechanical hypothesis of abrasion by giant papillae or the toxin hypothesis of cytotoxic deposition from eosinophils. Treatment depends on the grade of the ulcer and may involve medical therapy alone for grade 1, medical therapy with debridement for grade 2, or debridement and amniotic membrane transplantation for grade 3 to promote rapid re-epithelialization. Amniotic membrane transplantation acts as a physical barrier and helps reduce inflammation, scarring, and re-epithelialization times.

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    Shield Ulcer

    Uploaded by

    Allen Sally
    229 views9 pages
    Shield ulcers in vernal keratoconjunctivitis can form due to two hypothesized mechanisms: the mechanical hypothesis of abrasion by giant papillae or the toxin hypothesis of cytotoxic deposition from eosinophils. Treatment depends on the grade of the ulcer and may involve medical therapy alone for grade 1, medical therapy with debridement for grade 2, or debridement and amniotic membrane transplantation for grade 3 to promote rapid re-epithelialization. Amniotic membrane transplantation acts as a physical barrier and helps reduce inflammation, scarring, and re-epithelialization times.

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    Shield ulcers in vernal keratoconjunctivitis can form due to two hypothesized mechanisms: the mechanical hypothesis of abrasion by giant papillae or the toxin hypothesis of cytotoxic deposition from eosinophils. Treatment depends on the grade of the ulcer and may involve medical therapy alone for grade 1, medical therapy with debridement for grade 2, or debridement and amniotic membrane transplantation for grade 3 to promote rapid re-epithelialization. Amniotic membrane transplantation acts as a physical barrier and helps reduce inflammation, scarring, and re-epithelialization times.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    229 views9 pages

    Shield Ulcer

    Uploaded by

    Allen Sally
    Shield ulcers in vernal keratoconjunctivitis can form due to two hypothesized mechanisms: the mechanical hypothesis of abrasion by giant papillae or the toxin hypothesis of cytotoxic deposition from eosinophils. Treatment depends on the grade of the ulcer and may involve medical therapy alone for grade 1, medical therapy with debridement for grade 2, or debridement and amniotic membrane transplantation for grade 3 to promote rapid re-epithelialization. Amniotic membrane transplantation acts as a physical barrier and helps reduce inflammation, scarring, and re-epithelialization times.

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    SHIELD ULCER

    1
    SHIELD ULCER
    Two hypotheses for pathogenesis of shield ulcer:

    Mechanical Toxin
    hypothesis hypothesis

    Corneal
    damage

    2
    *Reddy, Jagadesh C., et al. "Management, clinical outcomes, and complications of shield ulcers in
    vernal keratoconjunctivitis." American journal of ophthalmology 155.3 (2013): 550-559.
    MECHANICAL HYPOTHESIS

    Corneal surface is abraded by


    the giant papillae on the
    upper tarasal conjunctiva.

     Explain the predilection of these


    ulcer to appear in superior part of
    the cornea

    N = 193 eyes

    3
    Reddy, Jagadesh C., et al. "Management, clinical outcomes, and complications of shield ulcers in
    vernal keratoconjunctivitis." American journal of ophthalmology 155.3 (2013): 550-559.
    TOXIN HYPOTHESIS

    A dense plaque is
    formed over shield
    ulcer by the
    deposition of toxic
    eosinophic granule
    major protein 
    secreted by activated
    eosinophils 
    cytotoxic and delays
    re-epithelization

    Takamura, Etsuko, et al. "Allergic Conjunctival Diseases." Allergology International 60 (2011): 191-203.


    THE MAIN AIM OF MANAGING SHIELD ULCERS

    • Preventing the release of toxic inflammation mediators


     Promote rapid re-epithelialization
    1 • By control VKC

    • Prevent direct mechanical trauma resulting from the large


    cobblestone papillae
    • By control VKC, AMT - amniotic membrane transplantation
    2

    • Provide a healthy environment for corneal epithelium


    • By debridement to remove the toxic inflammation
    3 material, ATM

    5
    Reddy, Jagadesh C., et al. "Management, clinical outcomes, and complications of shield ulcers in
    vernal keratoconjunctivitis." American journal of ophthalmology 155.3 (2013): 550-559.
    ROLES OF AMNIOTIC MEMBRANE TRANSPLANATION
    IN MANAGEMENT OF SHIELD ULCER
     Act as physical barrier:
     Preventing direct mechanical damage of the cornea by giant
    papillae.
     Preventing direct access of the toxins from activated
    eosinophils to the cornea and deposition of MBP present in
    abundance in tear film.
     Helping epithelial migration and anchoring
     Reducing corneal scaring
     By suppressing transforming growth factor ß signaling,
    proliferation and myofibroblast differentiation of normal
    corneal fibroblast.

    6
    Sridhar, M. S., et al. "Amniotic membrane transplantation in the management of shield ulcers of
    vernal keratoconjunctivitis." Ophthalmology 108.7 (2001): 1218-1222.
    Reddy, Jagadesh C., et al. "Management, clinical outcomes, and complications of shield
    ulcers in vernal keratoconjunctivitis." American journal of ophthalmology 155.3 (2013):
    550-559.

    Treatment options depend on grade of shield ulcer:


    Only medical (1)Medical treatment (1) Medical treatment
    treatment combined with combined with
    1) Sodium cromoglycate (2) Debridement. (2) AMT:
    2% or 4% - tid  When NO signs of re-
    2) Topical corticosteroid: (At slit lamp or in operating
    Prednisolone acetate 1% epithelialization wthin 2
    room using no.15 blade or weeks
    or fluorometholone the tip of 26 gauge needle)
    0.25% (glaucoma pts) –  After debirdement or
    4-8 times daily. suferfiacial keratoectomy.
    3) Antibiotic eye drops x 4
    times daily
    4) Lubricating
    Superficial keratoectomy : Signs of re-epithelialization:
    when only debridement decrease in size of epithelial
    failed to remove defect of at least 1mm from
    inflammation debris or the baseline within 2 weeks.
    plaque
    7
    Reddy, Jagadesh C., et al. "Management, clinical outcomes, and complications of shield
    ulcers in vernal keratoconjunctivitis." American journal of ophthalmology 155.3 (2013):
    550-559.

    N = 193 Grade 1 Grade 2 Grade 3


    71 (37%) 79 (41%) 43 (22%)
    Methods of treatment
    Only medical treatment 71 41 6
    Debridement 0 21 10
    AMT 0 17 27
    Re-epithelialized eye
    Only medical treatment 67 (94%) 36 (88%) 1 (17%)
    Debridement NA 20 (95%) 10 (100%)
    AMT NA 17 (100%) 27 (100%)
    Mean re-epithelialization time 20 days

    8
    Reddy, Jagadesh C., et al. "Management, clinical outcomes, and complications of shield
    ulcers in vernal keratoconjunctivitis." American journal of ophthalmology 155.3 (2013):
    550-559.

    Features Conclusion
    Grade 1 Shield ulcer with a Respond well to medical therapy
    clear base alone
    Grade 2 Ulcers with visible May required additional
    inflammatory debris diberdement or AMT
    at the base
    Grade 3 Shield ulcers with Largely refractory to medical
    elevated plaques therapy
    Required debridement and AMT
    for rapid re epithelialization

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