Management, Clinical Outcomes, and Complications of Shield Ulcers in Vernal Keratoconjunctivitis JAGADESH C. REDDY, SAYAN BASU, UJWALA S. SABOO, SOMASHEILA I. MURTHY, PRAVIN K. VADDAVALLI, AND VIRENDER S. SANGWAN  PURPOSE: To assess the clinical outcomes and complications of shield ulcers by various treatment methods.  DESIGN: Retrospective, interventional case series.  METHODS: SETTING: Cornea and anterior segment service of L.V. Prasad Eye Institute, India. STUDY POPULA- TION: One hundred ninety-three eyes of 163 patients clin- ically diagnosed with vernal keratoconjunctivitis and shield ulcers. INTERVENTION: The treatment algorithm was based on the Cameron clinical grading of shield ulcers. Grade 1 ulcers received medical therapy alone. Grade 2 and grade 3 ulcers received either medical therapy alone or medical therapy combined with debride- ment, amniotic membrane transplantation (AMT), or both. MAIN OUTCOME MEASURES: Re-epithelialization time and best-corrected visual acuity.  RESULTS: Grade 1 ulcers were seen in 71 (37%) eyes, grade 2 ulcers were seen in 79 (41%) eyes, and grade 3 ulcers were seen in 43 (22%) eyes. In the grade 1 group, re-epithelialization was seen in 67 (94%) eyes. In the grade 2 group, re-epithelialization was seen in 36 (88%) eyes that received medical treatment, in 20 (95%) eyes that underwent debridement, and in 17 (100%) eyes that underwent AMT. In the grade 3 group, re-epithelialization was seen in only 1 (1.7%) eye that received medical treatment, whereas it was seen in all eyes that underwent debridement and AMT. The mean best-corrected visual acuity after re-epithelialization of the shield ulcer was 20/30, 20/30, and 20/40 in the grade 1, grade 2, and grade 3 groups, respectively. Recurrence and secondary bacterial keratitis were seen in 28 (14.5%) and 20 (10%) eyes, respectively.  CONCLUSIONS: Grade 1 shield ulcers respond well to medical therapy alone, whereas grade 2 ulcers occasion- ally may require additional debridement or AMT. Grade 3 ulcers, however, largely are refractory to medical therapy and require debridement and AMT for rapid re-epithelialization. (Am J Ophthalmol 2013;-: -–-. Ó 2013 by Elsevier Inc. All rights reserved.) V ERNAL KERATOCONJUNCTIVITIS (VKC) IS a chronic bilateral allergic inflammation of the ocular surface, characterized by conjunctival hyperemia, chemosis, photophobia, intense itching, pseu- doptosis, filamentous mucous discharge, or a combination thereof. It may be seasonal or perennial (23%) and usually is seen in young boys in the first decade of their life. 1,2 VKC can present either in the palpebral form (giant papillary hypertrophy of the upper tarsal conjunctiva) or bulbar form (Tranta dots aggregates of epithelial cells and eosinophils) or a mixed form. Complications of VKC can be either disease related (shield ulcer, corneal scarring, dry eye, limbal stem cell deficiency) or treatment related (steroid-induced cataract and glaucoma). 3 Shield ulcer is a shallow indolent ulcer usually seen on the upper part of the cornea and takes months to re-epithelialize, depending on the severity. Two hypoth- eses have been proposed for the pathogenesis of shield ulcers. The mechanical hypothesis states that the corneal surface is abraded by the giant papilla on the upper tarsal conjunctiva, which explains the predilection of these ulcers to appear in the superior part of cornea. 4 The toxin hypothesis states that the inflammatory mediators from the eosinophils induce corneal epithelial damage. 5 Through either of the above mechanisms, initial corneal damage is manifested as coarse punctate epithelial keratop- athy, which is converted to corneal ulcers by the mechan- ical friction of the giant tarsal papillae. A dense plaque is formed over this ulcer by the deposition of toxic eosino- philic granule major basic protein, secreted by activated eosinophils, which is cytotoxic and delays re-epithelializa- tion. 6 Delayed epithelial healing may lead to secondary infections, 7–9 strabismus, amblyopia, 10 and corneal perfora- tion. 11 Several treatments have been used in various combinations to achieve rapid re-epithelialization, such as medical treatment (with corticosteroids, nonsteroidal anti-inflammatory drugs, antiallergic medications, cyclo- sporine), 12–14 temporary mattress sutures to the lids, 4 debridement, 15,16 superficial keratectomy, 11,15 amniotic membrane transplantation (AMT), 17 resection, and cryo- therapy, combined with AMT for giant papillae 18 and exci- mer laser phototherapeutic keratectomy. 19 In 1995, Cameron proposed a classification system for diagnosing, managing, and prognosticating shield ulcers based on the clinical features, which is the largest series (66 cases) published to date in the ophthalmic literature. 15 In this Accepted for publication Sep 12, 2012. From the Cornea and Anterior Segment Service, L. V. Prasad Eye Institute, Hyderabad, India (J.C.R., S.B., U.S.S., S.I.M., P.K.V., V.S.S.). Inquires to Virender S. Sangwan, Cornea and Anterior Segment Service, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Road No. 2, Banjara Hills, Hyderabad 500034, India; e-mail: vsangwan@lvpei.org 0002-9394/$36.00 http://dx.doi.org/10.1016/j.ajo.2012.09.014 1 Ó 2013 BY ELSEVIER INC.ALL RIGHTS RESERVED.