SHIELD ULCER

1
 SHIELD ULCER
Two hypotheses for pathogenesis of shield ulcer:

Mechanical Toxin
hypothesis hypothesis

Corneal
damage

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*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
treatment
1) Sodium cromoglycate
2% or 4% - tid
2) Topical corticosteroid:
Prednisolone acetate 1%
or fluorometholone
0.25% (glaucoma pts) –
4-8 times daily.
3) Antibiotic eye drops x 4
times daily
4) Lubricating
(1)Medical treatment (1) Medical treatment
combined with combined with
(2) Debridement. (2) AMT:
 When NO signs of re-
(At slit lamp or in operating
epithelialization wthin 2
room using no.15 blade or weeks
the tip of 26 gauge needle)
 After debirdement or
suferfiacial keratoectomy.
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

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