Huge nipples in the tarsal conjunctiva

Introduction The nipple hyperplasia of the palpebral conjunctiva caused by diseases such as keratoconjunctivitis in spring, which is the giant nipple of the conjunctiva, is one of the clinical manifestations of spring conjunctivitis. Spring keratoconjunctivitis, also known as spring catarrhal conjunctivitis, seasonal conjunctivitis. Pre-puberty onset, lasts 5-10 years, mostly for both eyes, the incidence of boys is higher than girls. The disease has a high incidence in the Middle East and Africa, low incidence in temperate regions, and almost no cases in cold regions. The incidence rate in spring and summer is higher than that in autumn and winter. The more accurate name for vernal conjunctivitis is vernal keratoconjunctivitis (VKC), a bilateral chronic external eye disease in which atopic individuals can respond to antigens prevalent in the environment. The main atopic diseases include eczema, asthma and urticaria. VKC mainly affects children and young adults, and is most common in spring, so it is called "spring" conjunctivitis. The affected patients are mainly characterized by external eye diseases, and the main symptoms are itching, tearing, shame and sticky secretions. The disease is "self-limiting." Currently available drugs have topical glucocorticoids and mast cell stabilizers. Spring keratitis is a recurrent conjunctivitis that is often affected by both eyes and can damage the corneal surface. The disease is usually caused by an allergic reaction, so it is more common in spring and summer. Spring conjunctivitis is mainly seen in children. It usually begins to develop in puberty and heals itself before the age of 20.

Cause

(1) Causes of the disease

The cause of the disease is unclear and may be related to atopy, with environmental and ethnic orientation.

(two) pathogenesis

VKC may involve more than one immunological mechanism. Direct and indirect evidence suggests that VKC may be a type I hypersensitivity response (rapid, IgE-dependent allergic response). Patients often have a family history of atopy or atopy. Histamine levels are elevated in tears. Histopathology revealed the presence of many degranulated mast cells in the parenchymal parenchyma and epithelial layers. Has a good therapeutic response to sodium cromoglycate. These facts suggest that VKC is an immune process mediated by IgE and mast cells. Although it is difficult to identify specific virulence factors that trigger abnormally excessive inflammatory responses, skin tests often show that patients are sensitized to several ubiquitous environmental antigens, especially to house dust mites.

However, only type I hypersensitivity reactions do not fully explain the histopathology of VKC. Histopathological and immunopathological features suggest that VKC may also be a combination of type I hypersensitivity (rapid hypersensitivity) and type IV hypersensitivity (delayed or cell-mediated hypersensitivity). . Histopathological studies of conjunctival nipples revealed a large number of monocytes, fibroblasts, and newly secreted collagen in addition to allergic cells (mast cells and eosinophils) in the nipple. There are helper (CD4) T cells in monocytes, especially Th2-type cells that secrete IL-4. Increased expression of HLA-II antigens in conjunctival epithelial cells and stromal cells was also found.

an examination

Related inspection

Fundus examination test

According to VKC, it is a bilateral chronic inflammation of the conjunctiva. The disease is seasonal, mostly common in children and young people. The characteristics of pubertal lesions begin to subside, and combined with the typical features of VKC - the huge nipple of the bilateral conjunctiva. Basically, the diagnosis can be determined. The main symptoms of the disease are persistent itching and worsening of symptoms at night. Signs should be focused on the diagnosis of typical lesions of the conjunctiva, corneoscleral, and cornea for clinical diagnosis.

The typical feature of VKC is the large nipple of the bilateral conjunctiva, but sometimes it also appears in the conjunctiva of the limbus. The main symptom is persistent itching. After various stimuli or induced environment during the day, such as dust, dandruff, light, wind, perspiration and rubbing, the tendency tends to increase at night. Other symptoms include pain, foreign body sensation, shame, burning sensation, tearing and sticky secretions. Symptom variability is a major feature of early VKC. As the disease progresses, the symptoms gradually worsen and in some cases are perennial. In 1888 Emmert divided VKC into eyelid type, corneoscleral type and mixed type. However, it is sometimes difficult to classify a case into a certain type. Therefore, considering VKC may have a more important classification significance depending on the severity of the symptoms and the clinical changes that attach importance to the affected tissue.

1. Conjunctival changes: the palpebral conjunctiva and the bulbar conjunctiva are the main affected sites of VKC. In the upper conjunctiva, a paving stone-like nipple reaction occurs, and the nipple sometimes fuses. These deciduous nipples are polygonal, with a flat head and visible visual inspection. However, these nipples are not disease specific. Under the slit lamp, the diameter of the nipple is 1 to 8 mm, which are connected to each other. Each nipple has one central blood vessel. Fluorescein can stain the top of the nipple. There is often a layer of sticky milky white secretion between the nipples and their surfaces, forming a sticky pseudomembrane. Follicular reactions are generally not observed in the affected conjunctival zone.

Changes in the limbus often occur in people of color. Mainly manifested as glia-like nodules or ridges in the limbal limbus, mostly located in the upper 1/2 of the limbeosalral region. The small white spot of the wart, called the Horner-Trantas point, consists mainly of inflammatory cells of eosinophils. Thinning, widening, and turbidity of the conjunctiva in the limbus can sometimes be observed.

2. Changes in the cornea: In patients with VKC, the extent of corneal involvement can be used as an indication of the severity of the disease. In patients with orbital VKC, up to 50% of cases have corneal pathology. Corneal complication is present in patients with orbital or mixed VKC almost without exception.

Epithelial keratitis is a common corneal manifestation, mainly characterized by the presence of spotted dark gray turbidity on the cornea 1/2, which is like dust. These punctiform turbidity can be broken and merged to form a large erosion. These erosion bases are shallow and have elevated edges, forming a dense layer of cell debris and mucus called the vernal plaque. Sometimes referred to as "shield ulcer," it usually only occurs in younger patients. Often located above the cornea, it is a horizontal ellipse. The ulcerated area often inhibits normal re-epithelialization. As a result, the erosion of the erosion zone is very slow, often resulting in permanent, gray, oval epithelial opacity. These corneal plaques rarely undergo vascularization unless chronic inflammation occurs. However, these ulcers are at risk of developing secondary microbial infections, resulting in permanent corneal sequelae.

Matrix keratitis can also occur in patients with VKC. The most common corneal degeneration change is the pseudo-aged ring, which approximates the aged ring. This curved surface layer turbidity is mainly located in the peripheral portion of the cornea, and there is often a space between the turbid area and the corneoscleral margin. In some cases, this focal yellow-gray opacity sometimes causes ulceration, causing a narrowing of the surrounding groove. Further changes will lead to myopic astigmatism. The pseudo-elderly ring is often accompanied by new blood vessels entering the peripheral part of the cornea, forming a vasospasm above the cornea.

3. Changes in the external eye: The eyelids may also have certain signs of VKC. Common signs of ptosis may be related to increased eyelid weight caused by secondary spring nipple hypertrophy. Excessive wrinkles (Dennie line) in the lower jaw skin are sometimes observed.

Differential diagnosis

The hard and flat nipple of the conjunctiva: due to the clinical manifestations of catarrhal conjunctivitis in the spring, the conjunctival hyperemia is very dramatic at the beginning, and then many hard and flat nipples occur in the upper conjunctiva, varying in size. It is covered with pebbles on the conjunctiva. The crack between the nipples is light blue, and the surface of the nipple presents a milky turbidity. There are not many secretions, it is very sticky, and it is drawn into a filament. For smear examination, it can be seen that eosinophils increase. If there is a lesion in the conjunctiva of the lower jaw, the nipple is small and small, and it is not as prominent as the conjunctiva. Spring vernal conjunctivitis is an allergic disease with a strong seasonality and often invades both eyes. Whenever the spring blossoms, the symptoms disappear and the symptoms disappear when the cold is late in the autumn. Recurrence every year, mild cases will not be issued after 3 to 4 years, severe cases can continue to relapse for more than 10 years. The disease is characterized by itchy eyes, large and flat nipples and conjunctival hyperplasia near the limbus, and a large number of eosinophils in the secretion.

The sputum conjunctiva appears as an off-white membrane: the appearance of an off-white film on the palpebral conjunctiva can be seen in various types of conjunctivitis, usually caused by infectious factors. Due to the leakage and hemorrhage of the new blood vessels, scars are formed and a permanent mechanical film is formed.

The material in this site is intended to be of general informational use and is not intended to constitute medical advice, probable diagnosis, or recommended treatments.