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

Reddy, Jagadesh C., et al. "Management, clinical outcomes, and complications 3of
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
2 transplantation

• Provide a healthy environment for corneal

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

Reddy, Jagadesh C., et al. "Management, clinical outcomes, and complications 5of
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.

Sridhar, M. S., et al. "Amniotic membrane transplantation in the management of 6

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 (1) Medical
treatment treatment combined treatment
1) Sodium cromoglycate with combined with
2% or 4% - tid (2) Debridement. (2) AMT:
2) Topical
corticosteroid:
 When NO signs of re-
Prednisolone acetate (At slit lamp or in epithelialization wthin
1% or fluorometholone operating room using 2 weeks
0.25% (glaucoma pts) no.15 blade or the tip of  After debirdement or
– 4-8 times daily. 26 gauge needle) suferfiacial keratoectomy.
3) Antibiotic eye drops x
4 times daily Superficial Signs of re-
4) Lubricating keratoectomy : when epithelialization:
only debridement failed decrease in size of
to remove inflammation epithelial defect of at
debris or plaque least 1mm from the
baseline within7 2 weeks.
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 Shield ulcer with a
1 clear base
Grade Ulcers with visible
2 inflammatory
debris at the base
Grade Shield ulcers with
3 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