Transcript Eleven Year Incidence of Microsporidial Keratitis in Singapore

A Loh, PY Boey & RS Loh
Singapore National Eye Centre
World Cornea Congress VI
Boston, Massachusetts, April 7-9, 2010
The authors have no financial interests in the subject
matter of this poster
Introduction
 Atopic keratoconjunctivitis (AKC) is a bilateral, chronic
inflammation of the conjunctiva and lids associated with atopic
dermatitis
 There is a male preponderance, with the onset of disease typically
in the second to fifth decade
 The major symptom is ocular itching which may be seasonal or
perennial
 Signs include
 Lids
eczema, blepharitis, meibomianitis & tarsal margin
keratinization
 Conjunctiva sub-epithelial fibrosis, symblepharon, fornix shortening & giant
papillae
 Cornea
superficial punctate keratitis, neovascularization & persistent
epithelial defects
 Shield ulcers, as defined as an epithelial defect with intact
Bowman’s membrane and an overlying fibrin/mucous plaque,
occurring in the superior half of the corneal surface is classically
associated with Vernal keratoconjunctivitis (VKC)
 In this study we report the incidence of four cases of inferior shield
ulcers occurring in atopic keratoconjunctivitis
Materials & Methods
 IRB review board approval
 Retrospective case series in one centre, CGH, from 01/01/05 to
30/12/08
 The diagnosis was based on the history and presentation of ocular
surface/corneal findings
 The following were assessed -
Risk factors -
Examination -
Atopic dermatitis
Snellen visual acuity
Asthma
Slit-lamp examination
Allergic rhinitis
Goldman tonometry
Results
 27 patients (24 bilateral) with allergic ocular disease were
identified in the 4 year study period
 AKC was present in 19 of these 27 patients (16 bilateral disease)
 Age at onset ranged from 10 to 30 years (mean 18.4 years, median 18).
with a male:female ratio of 4.75:1 (females n=4, 21.1%).
 Racial preponderance  Chinese
 Malay
74.9%
25.1%
(n=15)
(n=4)
 Follow-up period ranged from 4 to 72 months (median 4 weeks)
 Average recurrence rate was 1 per 4.7 months
 Number of recurrences ranged from 0 to 5 (median 2)
Results
 Pre-existing disease at presentation
 Asthma
 Eczema
 Allergic rhinitis
36.8% (n=7)
63.2% (n=12)
42.1% (n=8)
 Family history of atopic disease was present in 31.6% (n=6)
 Symptoms on presentation
 Itch and redness were present in all patients
 Mucoid discharge
 Watering
73.7% (n=14)
84.2% (n=16)
Results
 Visual acuity (VA)
 Best corrected VA (BCVA) ranged from 20/20 to 20/120 (median 20/30)
with final VA on resolution of 20/20 or better. There was no loss in lines of
BCVA.
 Minimum BCVA ranged from 20/20 to 20/200 (median 20/40)
 Slitlamp findings were as follows
 Giant papillae
 Limbal follicles
 Shield ulcers
 Corneal scars
68.4% (n=13)
31.6% (n=6)
31.6% (n=6)
26.3% (n=5)
 Treatment
 All patients were treated with topical mast cell stabilizer/anti-histamine (eg.
G Olopatadine 0.1%) and topical steroids (eg. Fluoromethalone 0.5%,
Dexamethasone 0.3% and Prednisolone Acetate 1.0%)
 Six patients (31.6%) required topical Cyclosporine A (CSA) 0.5% for long
term control
 There was no incidence of secondary cataract or glaucoma
Results
 Inferior shield ulcers occurred in 4 patients (21%). This was present in
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all cases in the left eye, with one having coincident upper shield ulcer
in the fellow eye
All patients were males, 3 were of Chinese and 1 of Malay racial
origin. Age at presentation ranged from 12 to 19 years
Pre-existing asthma, atopic disease and/or eczema was present in 3
patients
Bilateral disease was present in 3 patients
BCVA was 20/40 to 20/120 at presentation improving to 20/20 in all
cases with treatment. All shield ulcers resolved within 4 weeks using a
combination of topical Olopatadine 0.1% and Prednisolone Acetate
1.0%. Three patients required topical CSA 0.5% as maintenance
therapy
Giant papillae were present in 3 patients, with limbal follicles in one
Fig 1. Clinical patterns of inferior shield ulcers
a & b – inferior shield with mucous plaque
c & d – mucous plaque removed – epithelial defect revealed
Fig 1a
Fig 1b
Fig 1c
Fig 1d
Fig 2. Other features
a – inferior pseudogerontoxon
b – limbal follicles and meibomiatis
c & d – early superior shield ulcer with inferior corneal scar from healed inferior shield ulcer
Fig 2a
Fig 2b
Fig 2c
Fig 2d
Discussion
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This study demonstrates that inferior shield ulcers can occur in
atopic eye disease
The pathogenesis of inferior shield ulcers in VKC has been
previously described by Buckley
Inferior shield ulcers in AKC may be due to a combination of
keratinization of the lid margins, meibomianitis and late
presentation for treatment
Visual prognosis in this study group is good
The response to topical anti-histamine/mast cell stabilizers and
steroid therapy combination was good although maintenance
therapy with topical CSA 0.5% was required in 31% (n=6) of
cases. This may partly explain the absence of secondary
glaucoma
References
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Buckley RJ. Vernal keratoconjunctivitis. Int Ophthalmol Clin 1988 28:303-308
Tuft SJ, Kemeny DM, Dart JK et al. Clinical features of atopic keratoconjunctivitis. Ophthalmology. 1991 Feb;98(2):150-85
Foster CS, Calonge M. Atopic keratoconjunctivitis. Ophthalmology. 1990 Aug;97(8):992-1000
Hingorani M, Moodaley L, Calder VL et al. A randomized placebo controlled trial of topical cyclosporin A in steroid-dependent atopic
keratoconjunctivitis. Ophthalmology. 1998 Sept;105(9):1715-20
Anzaaf F, Gallagher MJ, Bhat P et al. Use of systemic T-lymphocyte signal transduction inhibitors in the treatment of atopic keratoconjunctivitis.
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