Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Aug 2018

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case report
Year : 2008 | Month : August | Volume : 2 | Issue : 4 | Page : 1013 - 1016 Full Version

Scraping Of Ulcer Base Hastens The Healing Of Grade 3 Shield Ulcer In Vernal Keratoconjunctivitis.

Published: August 1, 2008 | DOI:

Mohammad Dossary Hospital PO Box 335, Al Khobar 31952 Saudi Arabia

Correspondence Address :
Kumar S, Mohammad Dossary Hospital PO Box 335, Al Khobar 31952 Saudi Arabia Tel- 009660568245613
Fax- 00966 3 8950735 Email:


A 10-year-old boy presented with complaints of pain and photophobia in the left eye. Slit lamp examination revealed cobble stone papillae in both tarsal conjunctivae, diffuse punctate epitheliopathy of cornea and a 3.5x1.5 mm epithelial defect in the left eye. He was diagnosed to be suffering from bilateral vernal keratoconjunctivitis, with evolving grade 3 shield ulcer in the left eye. Shield ulcer was refractory to the combined regime of topical corticosteroids, dual acting antihistamine and lubricating eye drops.
After removal of plaque and scrapping of base, the ulcer re-epithelialized completely in two weeks, leaving behind an opacity which stained negatively with fluorescein dye. The patient was followed up for two months and no recurrence of ulcer was noted.
Drug resistant shield ulcer with plaque re-epithelialized rapidly after removal of plaque and scrapping of base of ulcer.


Shield ulcer, vernal keratoconjunctivitis

Shield ulcer is an uncommon, incapacitating corneal manifestation that occurs in 3 to 11% of patients suffering from vernal keratoconjunctivitis(1). To prevent the vision threatening complications of shield ulcer, it should be treated aggressively and appropriately. Treatment of shield ulcer may vary from topical medication to surgical intervention, depending on the grade of ulcer. Removal of plaque and scrapping of base hasten the re-epithelialization of drug resistant shield ulcer.

Case Report

A 10-year-old boy from Somalia attended our Out Patient’s Department with a history of redness, itching and watering of eyes, which waxed and waned for almost three years. The redness, itching, watering and thick discharge were persistent in both eyes for the past one year, but he was incapacitated by photophobia and pain in the left eye for the past three months only. During the past six weeks, he was applying Livocabastine and Tobramycin-Dexamethasone eye drops four times daily for the diagnosis of severe vernal keratoconjunctivitis. His best corrected visual acuity was 6/18 OD and 6/36 OS. Biomicroscopy revealed bilateral congested conjunctivae, grade 4 cobblestone papillae and diffuse punctate epitheliopathy of cornea, along with a 3.5x1.5 mm epithelial defect in the left eye which stained positively with fluorescein dye. As the inferior part of the ulcer had a clear base while the superior half exhibited obvious inflammatory debris and thick plaque, he was diagnosed to be suffering from bilateral vernal keratoconjunctivitis with evolving grade 3 shield ulcer in the left eye. His visual acuity was compromised because of bilateral superficial punctate epitheliopathy, along with corneal shield ulcer in left eye. Treatment was commenced with Fluorometholone eye drops, four times per day, Olopatadine eye drops, two times per day and Sodium Hyaluronate eye drops, six times per day. After five days, the symptom-complex improved slightly, but the shield ulcer remained essentially unchanged. (Table/Fig 1) Fluorometholone eye drops were replaced with Prednisolone 1% eye drops which were applied four times daily. The patient was examined one week later, but the shield ulcer did not regress appreciably.

(Table/Fig 2)Removal of plaque was advised. After topical anaesthesia, the plaque was removed with the tip of 26 gauge needle and ulcer base was scrapped with the edge of same needle, under the slit lamp. The eye was patched for twenty four hours. After twenty four hour, the earlier regime of topical Prednisolone, Olopatadine and Sodium Hyaluronate was reinstituted.

(Table/Fig 3)Five days after removal of plaque, remarkable decrease in size of the ulcer was noted.

(Table/Fig 4)Twelve days later, the ulcer re-epithelialized almost completely. (Table/Fig 5)Twenty days after removal of plaque, the ulcer healed completely, leaving behind a nebular grade corneal opacity which stained negatively with Fluorescein dye.
(Table/Fig 6) The best corrected visual acuity improved to 6/9 partial in the left eye. The corticosteroids were tapered gradually, and symptoms of vernal keratoconjunctivitis were controlled satisfactorily by Olopatadine and Sodium Hyaluronate eye drops.

The patient was followed up for two months, and the ulcer did not recur.


VKC is a chronic seasonally exacerbated allergic inflammation of the ocular surface involving the tarsal and/or bulbar conjunctiva (2). VKC is not a blinding disease, but visual impairment is not uncommon if the cornea is involved. Although punctate epitheliopathy is the commonest, shield ulcer with or without plaque, keratoconus, hydrops, pseudogerontoxon and corneal opacification, are not uncommon manifestations of corneal involvement in VKC (3). Coalescence of punctate erosion may lead to a large epithelial defect known as shield ulcer. In the event of inappropriate or no treatment, a plaque containing fibrin and mucus deposits on this epithelial defect which hampers the re-epithelialization of shield ulcer (4). In the treatment of shield ulcer, topical antihistamines, dual action drugs, lubricants and corticosteroids are the first line of defence. Supratarsal corticosteroid injections(5), topical cyclosporine(6), cryotherapy, surgical or laser(7) assisted excision of giant papillae with(8) or without mitomycine, excimer laser phototherapeutic keratectomy(9), amniotic membrane graft(10) and cultivated corneal epithelial cells transplant(11), have been tried for non-healing shield ulcer with varying degrees of success. Recalcitrant shield ulcers may progress to visual threatening complications such as infective keratitis, corneal opacity, perforation, strabismus and amblyopia, and should be treated appropriately and aggressively. Based on their clinical characteristics, response to treatment and complications, shield ulcers can be classified into three grades (12). Shield ulcers with a clear base [Grade 1] have a favourable outcome and re-epithelialize with mild scarring on medical treatment. Ulcers with visible inflammatory debris in the base [Grade 2] exhibit poor response to medical therapy. Because of delayed re-epithelialization shield ulcers may develop infective keratitis. Grade 2 shield ulcers, unresponsive to combined therapy with topical corticosteroids, Olopatadine and lubricating eye drops heal rapidly after adding commercially available preparations of topical cyclosporine (13). Shield ulcers with elevated plaque [Grade3] need surgical intervention (14). On histopathological examination, plaques are found to have granular and deeply oeosinophilic lamellar material attached to the Bowman layer. Immunohistochemistry confirmed this lamellar material to be oeosinophil derived major basic protein (MBP), which possesses cytotoxic properties, and is probably responsible for the delayed ulcer healing (15).

The Shield ulcer in this patient exhibited all three stages of evolvement of shield ulcer which re-epithelialized rapidly after removal of plaque and scraping of ulcer base.


Bonini S, Bonini S, Lambiase A, Marchi S, Pasqualetti P, Zuccaro O, Rama P, Magrini L, JuhasT, Bucci MG. Vernal keratoconjunctivitis revisited: A case series of 195 patients with long-term follow-up, Ophthalmology 2000;107:1157-63
Barney NP. Vernal and atopic keratoconjunctivitis. In Krachmer JH, Mannis MJ, Holland EJ, Eds. Cornea and External Disease: Clinical Diagnosis and Management. Vol.2, St Louis : Mosby-Year Book, Inc, 1997. 811-17.
Iqbal A, Jan S, Babar TF, Khan MD. Corneal complications of vernal catarrh. J Coll Physicians Surg Pak 2003; 13:394-97.
Rahi AHS, Buckley R, Grierson I. Pathology of corneal plaque in vernal keratoconjunctivitis. In O’ Connor GR, Chandler JW, eds. Advances in immunology and immunopathology of eye. New York : Masson. 1985.
Singh S, Pal V, Dhull CS. Supratarsal injection of corticosteroids in the treatment of refractory vernal keratoconjunctivitis. Indian J Ophthalmol 2002;50: 160-61.
Cetinkaya A, Akova YA, Dursun D, Pelit A. Topical cyclosporine in the management of shield ulcers.. Cornea 2004; 23:194-200.
Belfair N, Monos T, Levy J, Mnitentag H, Lifshitz T. Removal of giant papillae by CO2 laser. Can J Ophthalmol 2005;40:472
Tanaka M, Takano Y, Dogru M, Fukagawa K, Asano-Kato N, Tsubota K, Fujishima H. A comparative evaluation of the efficacy of intraoperative mitomycin C use after the excision of cobblestone-like papillae in severe atopic and vernal keratoconjunctivitis. Cornea 2004; 23:326-29.
Cameron JA, Antonios SR, Badr IA. Excimer laser phtotherapeutic keratectomy for shield ulcers and corneal plaques in vernal keratoconjunctivitis.. J Refract Surg. 1995; 11:31-35.
Rouher N, Pilon F, Dalens H, Fauquert JL, Kemeny JL, Rigal D, Chiambaretta F. Implantation of preserved human amniotic membrane for the treatment of shield ulcer and persistent corneal epithelial defects in chronic allergic keratoconjunctivitis. J Fr Ophthalmol 2004; 7:1091-97.
Sangwan VS, Murthy SI, Vemuganti GK, Bansal AK, Gangopadhyay N, Rao GN. Cultivated corneal epithelial transplantation for severe ocular surface disease in vernal keratoconjunctivitis. Cornea. 2005; 24:426-30.
Cameron JA. Shield ulcers and plaques of cornea in vernal keratoconjunctivitis. Ophthalmology 1995; 102:985-93.
Kumar S.Combined therapy for vernal shield ulcer:A case report.Clin Exp Optom 2008;91:111-14.
Ozbek Z, Burakgazi AZ , Rapuano CJ. Rapid healing of vernal shield ulcer after surgical debridement: A case report. Cornea 2006;25: 472-73.
Solomon A, Zamir E, Levartovsky S, Frucht-Pery J. Surgical management of corneal plaques in vernal keratoconjunctivitis: a clinicopathologic study. Cornea 2004;23:608-12

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