Images in Clinical Medicine

Vernal Keratoconjunctivitis

James Homme, M.D., and Jeff Wiswell, M.D.

N Engl J Med 2012; 366:647February 16, 2012

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An otherwise healthy 6-year-old boy presented to the emergency department with a 2-year history of what his mother referred to as “eye problems.” She reported noticing “whitish specks” surrounding both irises, which had been increasing in size. The boy was active and did not have any signs of diminished visual acuity, but his mother reported that he occasionally said that his eyes were itchy. Inspection revealed raised, symmetrical, white papules, 2 mm in diameter, between the 10 and 2 o'clock positions of the limbus in each eye; eggshell-like flecks with a calcific appearance could be seen in the center of this area. A clinical diagnosis of vernal keratoconjunctivitis was made, given the presence of classic giant papillae, with a cobblestone appearance (arrow), at the limbus. (The patient was asked to look at his nose for the purposes of the photograph.) Vernal keratoconjunctivitis typically affects males between 5 and 20 years of age and often resolves spontaneously at puberty. Both eyes are generally involved, and patients often report ocular burning or itching, tearing, and photophobia. Diagnosis is typically based on the clinical findings of giant cobblestone papillae on the tarsal conjunctiva or at the limbus. Treatment consists of saline eyedrops, which help to relieve symptoms, along with topical antihistamines and nonsteroidal antiinflammatory drugs.

James Homme, M.D.
Jeff Wiswell, M.D.
Mayo Clinic, Rochester, MN