CASE REPORT Papilloma Development and Long-term Ciclosporin Use in Chronic Ocular Allergy With Associated Keratoconus Bita Manzouri, M.R.C.P., F.R.C.Ophth., Ph.D., Philip J. Luthert, F.R.C.P., F.R.C.Path., F.R.C.Ophth., and D. Frank P. Larkin, M.D., M.R.C.P.I., F.R.C.S. Purpose: Conjunctival papillomata are squamous epithelial tumors with a strong association with human papilloma virus (HPV) types 6 and 11. They are benign conjunctival tumors that can be treated by surgical excision. We report a case where topical immunosuppressive therapy modified the local T-cell immunity in the conjunctiva resulting in papilloma development in a patient with keratoconus and a strong atopic history. Methods: A case report of a 44-year-old man with a history of severe ocular and generalized atopy is presented. We present the problems encountered in management of his severe ocular allergy and how these impeded the management of his keratoconus. Results: Conventional antiallergy topical medication was not producing symptom relief in this patient, and so topical immunosuppression was commenced using ciclosporin ointment 0.2%. This therapy modified the local T-cell immunity in the conjunctiva resulting in the development of papillomata which contributed to the intolerance of contact lens wear for visual rehabilitation of the keratoconus in the patient. These lesions were surgically removed but typically recurred and required further surgical excision. Adjunct cryotherapy was also performed at the time of the surgery to try to stem the recurrence of the papillomas. Conclusions: To the best of our knowledge and following a review of the published literature using key databases that include Medline and PubMed, this is the first report confirming the development of conjunctival papillomas secondary to HPV type 6 in a ciclosporin-treated patient. Key Words: Atopic keratoconjunctivitis—Conjunctival papilloma—HPV type 6—HPV type 11—Ciclosporin. (Eye & Contact Lens 2013;39: 402–404) H uman papillomata are neoplasms of epithelial origin found in numerous anatomical locations (e.g. skin, conjunctiva, and cervix). They are characteristically lobulated with a central vascular core and may rarely undergo malignant change. Conjunctival pap- illomata in particular are benign squamous epithelial tumors with minimal malignant potential. A strong association exists between human papilloma virus (HPV) types 6 and 11 and the development of conjunctival papillomas. 1 We report on a case of HPV arising on a background of ocular allergy in a patient using local long-term immunosuppressive therapy. METHODS A 44-year-old man with a history of atopic keratoconjunctivitis, asthma, and atopic dermatitis had been under the care of the contact lens and the external disease clinics for more than 17 years for associated keratoconus. His asthma was well controlled with the use of a regular salbutamol inhaler supplemented with the occasional use of a steroid inhaler for acute exacerbations. His atopic dermatitis was controlled with the use of topical emollients. Ocular treatment during this time comprised the use of mast cell–stabilizing agents supple- mented with intermittent topical steroids for allergy exacerbations. Topical ciclosporin 0.2% ointment at night was added, both as a steroid sparing agent and to improve symptom control. RESULTS Seven months after commencement of ciclosporin alongside intermittent topical steroid use, bilateral large upper tarsal con- junctival papillomas were noticed (Fig. 1). These lesions started interfering with his contact lens wear for his keratoconus and necessitated their surgical removal. After surgery, ciclosporin oint- ment use continued twice daily to control symptoms along with topical mast cell–stabilizing agents only. Papilloma recurrence was observed within 12 months and further excision was necessary FIG. 1. Papillomatous lesions on the upper tarsal conjunctiva. From the Departments of Paediatrics and Strabismus (B.M.) and Department of Cornea and External Disease (F.P.L.), Moorfields Eye Hospital, London, United Kingdom; and Division of Pathology (P.J.L.), UCL Institute of Ophthalmology (F.P.L.), London, United Kingdom. The authors have no funding or conflicts of interest to disclose. Address correspondence to Bita Manzouri, M.R.C.P., F.R.C.Ophth., Ph.D., Department of Paediatrics and Strabismus, Moorfields Eye Hospital, City Road, London EC1V 2PD, United Kingdom; e-mail: bita.manzouri@ moorfields.nhs.uk Accepted June 3, 2013. DOI: 10.1097/ICL.0b013e31829e905e 402 Eye & Contact Lens  Volume 39, Number 6, November 2013 Copyright @ Contact Lens Association of Opthalmologists, Inc. Unauthorized reproduction of this article is prohibited.