Limbal vernal is primarily located on the limbus, especially the superior limbus. In the latter form of the disease, the limbus has a thickened, gelatinous appearance with scattered opalescent mounds and vascular injection. ‘Horner-Trantas’ dots (collections of active and degenerated eosinophils and epithelial cells) can be observed within the hypertrophic limbal tissues in both forms. Sterile epithelial ulcers with an oval or shield shape, and underlying stromal Opacification, may also develop in the midsuperior cornea. The ulcers are more common in cases of palpebral vernal and are difficult to treat. Occasionally both the palpebral and the limbal forms of vernal are observed in the same patients. Treatment of vernal keratoconjunctivitis consists of topical vasoconstrictor-antihistamines and strict environmental controls, including home air-conditioning. Topical cromolyn sodium, steroids and non-steroidal anti-inflammatory drugs can provide significant relief.

GIANT PAPILLARY CONJUCTIVITIS : Giant papillary conjunctivitis (GPC) is chronic inflammation of the conjunctiva with prominent papillary hypertrophy of the superior tarsus. This condition occurs in patients who wear soft contact lenses, although GPC sometimes occurs in patients who wear hard contact lenses. GPC is also been in patients with ocular prostheses, loose nylon sutures, filtering blebs, and other conditions that may constitute an irritative or allergic stimulus. Definitive therapy for this condition includes exchanging the offending contact lens for a new one, changing the lens materials or edge design, or increasing the frequency of enzymatic lens cleaning. Disposable soft contact lenses or gas permeable lenses can also be an effective alternative. In the extreme cases, contact lens wear should be discontinued. Topical mast cell stabilizers may provide symptomatic relief but will not relieve the underlying condition.

SUPERIOR LIMBIC KERATOCONJUNCTIVITIS: Superior limbic keratoconjunctivitis (SLK) is a chronic, idiopathic recurrent condition characterized by ocular irritation and redness. It is often bilateral, although one eye may be more severely affected than the other. One or more of the following external ocular signs are seen in patients with SLK: a fine papillary reaction on the superior tarsal conjunctiva; injection and thickening of the superior bulbar conjunctiva and hypertrophy of the superior limbus; and fine punctate fluorescein and rose Bengal staining of the superior bulbar conjunctiva above the limbus and of the superior cornea just below the limbus. A filamentary keratitis involving the superior fifth of the cornea is frequently seen as well. SLK has been shown to be associated with hyper- and hypothyroidism. Ocular symptoms may improve with appropriate thyroid management. Various therapies have been reported to provide temporary or permanent relief of symptoms which includes chemical cauterization of the superior bulbar conjunctiva and superior tarsal conjunctiva with a 0.5% to 1% solution of silver nitrate (silver nitrate sticks should never be used; they will cause corneal Opacification); large-diameter bandage contact lenses; thermal cauterization of the superior bulbar conjunctiva; and resection of the superior bulbar conjunctiva superior to the limbus.