The Study of Rebamipide for the Treatment of Vernal Keratoconjunctivitis at a Tertiary Care Center in North India

Niraj Kumar Yadav^1*, Ahmad Husain², Deepti Joshi³, Brijesh Singh⁴, Ravi Ranjan⁵

¹Assistant Professor, Department of Ophthalmology, Dr. KNS MIMS, Lucknow, UP, India
²Assistant Professor, Department of Ophthalmology, UPUMS, Saifai, Etawah, UP, India
³Assistant Professor, Department of Ophthalmology, UPUMS, Saifai, Etawah, UP, India
⁴Professor, Department of Ophthalmology, UPUMS, Saifai, Etawah, UP, India
⁵Professor and Head, Department of Ophthalmology, UPUMS, Saifai, Etawah, UP, India

*Correspondence author: Niraj Kumar Yadav, Assistant Professor, Department of Ophthalmology, Dr. KNS MIMS, Lucknow, UP, India; Email: dr.nirajyadav@gmail.com

Citation: Yadav NK, et al. The Study of Rebamipide for the Treatment of Vernal Keratoconjunctivitis at a Tertiary Care Center in North India. J Ophthalmol Adv Res. 2025;6(2):1-11.

Copyright^© 2025 by Yadav NK, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Table 1: Clinical scoring system (Bleik, et al.,). Severity score of symptoms of VKC [11]; Total Subjective Symptoms Score (TSSS) [4].

Table 2: Severity score of signs of VKC Total Objective Ocular Sign Score (TOSS) [4,11].

Results

Table 3 The data indicate a notable male preponderance in the prevalence of the disease, with a significant concentration among children aged 6 to 10 years, yielding a mean age of 10.2 years and a standard deviation of 4.05 years. According to the modified Kuppuswamy scale, most patients fall into the upper-lower socioeconomic class, followed closely by those identified in the lower socioeconomic class. In terms of clinical presentation, the limbal form of VKC emerges as the most prevalent type within the study population, outpacing the mixed form, while the palpebral form is observed to be the least common variant. Interestingly, most patients in the cohort do not exhibit any accompanying systemic allergic conditions. However, when such associations do exist, they predominantly manifest as allergic rhinitis, asthma and atopic dermatitis, with allergic rhinitis and asthma being more frequently observed than other systemic allergic diseases. This highlights the importance of monitoring for potential co-morbidities in patients diagnosed with VKC, especially during the critical developmental years.

Table 3: Demographic profile of cases.

Table 3 The incidence of Vernal Keratoconjunctivitis varies by age across different groups, with the highest prevalence occurring in the 6 to 10-year age bracket. In this age group, the limbal form is more common than the mixed form, while the palpebral form is the least prevalent type of VKC. The p-value of 0.006 indicates a statistically significant difference between age groups and the type of VKC.

Table 4: Association between Age Group and VKC type.

Table 5 The gender distribution across various forms of VKC indicates that males are more frequently affected than females in all types of VKC. However, the p-value of 0.548 indicates that there is no statistically significant difference between sex and VKC type, suggesting that both males and females are equally susceptible to the different forms of VKC.

Table 5: Association between sex and VKC type.

Fig. 1 the mean values of the Total Subjective Symptom Score (TSSS) and Total Objective Sign Score (TOSS) at baseline, as well as during subsequent follow-ups, particularly at the 12-week mark, indicate a significant reduction in both TSSS and TOSS. This finding suggests that Rebamipide eye drops are an effective topical treatment for managing Vernal Keratoconjunctivitis.

Figure 1: The mean values of the Total Subjective Symptom Score (TSSS) and Total Objective Sign Score (TOSS) at baseline.

Table 6 the Analysis of Variance (ANOVA) reveals compelling findings regarding the treatment of vernal keratoconjunctivitis with topical Rebamipide. Initially, the mean baseline TSSS (Total Subjective Symptom Score) is recorded at 10.29, reflecting a significant burden of symptoms. Remarkably, after a 12-week treatment period, this score diminishes to a mere 1.46, indicating a profound reduction in symptom severity. The P-value of 0.00001 underscores the statistical significance of this difference, strongly suggesting that topical Rebamipide is a highly effective therapeutic option for alleviating the symptoms associated with this ocular condition. Following a comprehensive post hoc analysis of the ANOVA, the findings reveal a noteworthy and significant difference in the mean scores of the Total Subjective Symptoms Score (TSSS) when compared to baseline measurements taken at the start of the study and again at the conclusion of the 12-week intervention period. This notable shift in scores indicates a significant change in participants’ stress levels over the study’s duration, highlighting the potential effectiveness of the Rebamipide eyedrop.

Table 6: ANOVA Test for evaluation of TSSS.

Discussion

Vernal Kerato-Conjunctivitis (VKC) can cause severe, debilitating symptoms in young people. The name “spring catarrh” comes from the fact that it is more common in the tropics and in the spring. A total of 270 patients (510 eyes) were included in the present study. All 270 patients who received treatments were included in the efficacy and efficiency analysis. The study reveals a male predominance of the disease, with the highest incidence observed in the 6 to 10 age group, averaging 10.2 years. According to the modified Kuppuswamy scale, most patients are classified in the upper lower socioeconomic class, followed by the lower class. Among the different forms of VKC, the limbal variant is the most common, while the mixed form follows and the palpebral form is the least frequent. Within specific age groups, the same order of prevalence has been observed (Table 3,4). Analysis of gender distribution in VKC shows that males are more frequently affected than females. However, with a p-value of 0.548, this difference is not statistically significant, indicating that both sexes have similar vulnerability to VKC’s various forms (Table 5). Most patients do not have other systemic allergic conditions; however, when such associations do exist, they typically present as allergic rhinitis, asthma or atopic dermatitis, with allergic rhinitis and asthma being the most prevalent. In a comprehensive 7-week study, researchers examined the therapeutic potential of Rebamipide 2% in patients suffering from allergic ocular diseases. The findings revealed that this formulation not only effectively mitigated the objective signs but also significantly reduced the subjective symptoms of eye discomfort, including persistent itchiness and an overwhelming sensation of dryness reported by participants (Table 6). Recent findings indicate that Rebamipide 2% has an impressive safety profile, with very few side effects reported, which highlights its tolerability among patients. These results suggest that topical Rebamipide 2% could emerge as the preferred first-line treatment for certain cases of dry eye syndrome. Additionally, it may serve as an effective adjunct therapy for those suffering from allergic ocular conditions [30]. Recurrent VKC is a chronic eye condition mostly affecting children and young adults. It involves fluctuations in the immune response of the eye, often worsened by seasonal allergens like pollen and dust mites. This episodic inflammation can damage the ocular surface and negatively impact vision and eye health over time [24]. As recurrences of VKC decrease, patients often experience less photophobia and wind sensitivity. Improvements in tear film quality help protect the ocular surface and enhance visual clarity. Addressing recurrent VKC is crucial for immediate symptom relief and long-term ocular health [31]. Managing VKC requires a comprehensive approach that considers factors like the patient’s age, symptom severity and chronicity. This complexity can challenge even experienced ophthalmologists, as treatment responses vary. Alongside pharmacological options, non-pharmacological strategies are essential. Identifying and avoiding triggers, such as pollen and dust, as well as adopting lifestyle modifications like good eye hygiene and protective eyewear during allergy seasons, can help alleviate symptoms. This holistic management aims to improve the overall quality of life for those affected by VKC [32]. To manage VKC effectively, use soothing artificial tears for immediate relief and apply cold compresses to reduce swelling. Stylish sunglasses can protect your eyes from UV rays and allergens. Most importantly, avoid exposure to allergens to diminish symptoms. Following these steps will help lessen discomfort, swelling and redness associated with VKC [33-35]. There are various therapeutic options for treating VKC, including antihistamines, mast cell stabilizers such as sodium cromoglycate, dual-acting combinations, alpha-adrenergic agonists (vasoconstrictors), Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), immunomodulators (cyclosporin A, tacrolimus) and corticosteroids [36]. In 2008, Tacrolimus 1% ophthalmic suspension was approved. Since then, it has been widely used off-label with varying formulations at concentrations from 0.003% to 1.0% have shown significant improvement in signs and symptoms of VKC with negligible systemic absorption. Tacrolimus ointment is approved primarily as a second-line therapy for moderate to severe atopic dermatitis. Within this indication, only 0.03% concentration is indicated for use in children 2-15 years of age [37-44]. A combination therapy that employs a dual mechanism includes antihistamines and mast cell stabilizers to deliver both immediate and prolonged symptomatic relief for patients suffering from ocular allergies. Topical agents with this dual mechanism of action comprise olopatadine in concentrations of 0.1%, 0.2% and 0.7%, as well as bepotastine besilate at 1.5%, azelastine at 0.05% and alcaftadine at 0.2% [45]. Dupilumab, a humanized monoclonal antibody, acts as a leukotriene antagonist by blocking IL-4, IL-13 and Th2-mediated inflammation, which are involved in the development of conjunctival papillae in ocular allergy [46]. Initially approved for severe, refractory atopic dermatitis, clinical trials have indicated an increase in conjunctivitis and keratitis among patients using dupilumab [47]. A claims database analysis of 2144 patients from January 1, 2016, to June 30, 2019, also noted more medical encounters for ocular surface disorders after starting the treatment [48]. A recent case reports suggest that patients with atopic conditions, severe Allergic Keratoconjunctivitis (AKC) and VKC treated with dupilumab experienced improvements in symptoms, including a reduction in the size of giant papillae [49-52]. Interleukin-5 plays a crucial role in the recruitment and activation of eosinophils, which are essential for inflammatory responses in the body. In the treatment of asthma and allergic ocular disorders, three monoclonal antibodies-benralizumab, mepolizumab and reslizumab-have emerged as effective therapies. Each of these treatments targets specific pathways within the immune system, offering a promising approach to alleviating symptoms associated with these conditions. Additionally, accumulating evidence indicates that these therapies may offer significant benefits in managing VKC and other ocular allergic conditions [53]. A newly introduced medication, Omalizumab, is a recombinant humanized monoclonal antibody that binds to free Immunoglobulin E (IgE), a key player in allergic reactions. While it is approved for severe persistent asthma, there are promising off-label uses for treatment-resistant VKC [54,55]. Recently, Ueta, et al., introduced the drug, Rebamipide, a quinolone-class derivative, which acts as a mucin secretagogue, enhancing protective mucin secretion. It reduces pro-inflammatory cytokines IL-6 and IL-8, decreases eosinophilic infiltration and inhibits TNF-α, a key inflammatory mediator [21]. Clinical studies show that Rebamipide effectively decreases papillary formation in patients with VKC and AKC, especially those unresponsive to traditional therapies. However, some patients may experience side effects like dysgeusia and eyelid pruritus [22].  Koh, et al., reported that rebamipide markedly enhances tear film breakup time. Their findings revealed significant improvements from baseline measurements, showcasing notable upward trends in total corneal higher-order aberrations, as well as reductions in both coma-like and spherical-like aberrations following the application of rebamipide [56]. Takahashi, et al., conducted a study revealing that patients with thyroid eye disease who also experienced Superior Limbal Keratoconjunctivitis (SLK) exhibited significant improvements after treatment with topical rebamipide. Remarkably, 84.8% of these patients experienced a complete resolution of SLK following the treatment. The authors concluded that topical rebamipide could potentially serve as a first-line therapeutic option for managing SLK in this patient population, highlighting its efficacy in addressing this challenging condition [57]. In a separate investigation, the application of topical rebamipide demonstrated significant effectiveness in alleviating corneal and conjunctival disorders associated with lid-wiper epitheliopathy. This study highlighted the agent’s potential to improve ocular surface health and address the specific challenges presented by this condition [58]. In a separate case report, rebamipide was administered to patients with Sjögren’s syndrome who exhibited erosion in the inferior cornea following surgical punctal occlusion. This treatment aimed to alleviate discomfort and promote healing in these individuals, addressing the complications that arose from their condition and the surgical intervention [59]. The study shows that rebamipide ophthalmic suspension effectively treats corneal epithelial damage from tear deficiency and low mucin levels. It helps restore the microstructure of corneal and conjunctival surfaces, enhancing tear film stability and reducing inflammatory reaction. The therapeutic effects were evaluated through improvements in subjective symptom scores and objective sign scores after 12 weeks (Graph 1), highlighting Rebamipide’s potential to promote ocular health and comfort [60]. Based on Rebamipide’s ability to modify conjunctival and corneal epithelial cell functions, the authors suggested that this may open new strategies for treating human ocular surface inflammation, including allergic conjunctivitis and dry eye diseases.

Conclusion

Rebamipide 2% ophthalmic suspension was launched in Japan, marking a significant advancement in the treatment of dry eye syndrome. Clinical studies demonstrate that it offers significant benefits over traditional therapies, such as lubricants. Our experience indicates that rebamipide effectively improves severe ocular allergic conditions, leading to a notable reduction in symptoms of Vernal Kerato-Conjunctivitis (VKC) after 12 weeks of treatment. It can be used as monotherapy or alongside other medications, with no serious adverse effects recorded. Overall, rebamipide proves to be an effective option for managing moderate to severe VKC and may reduce reliance on harmful long-term immunosuppressive therapies.

Conflict of Interest

The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding Details

No author has a financial or proprietary interest in any material or method mentioned.

References

1. Iijima K, Ichikawa T, Okada S. Rebamipide, a cytoprotective drug, increases gastric mucus secretion in humans: evaluations with endoscopic gastrin test. Dig Dis Sci. 2009;54:1500-7.
2. Ishihara K, Komuro Y, Nishiyama N. Effect of Rebamipide on mucus secretion by endogenous prostaglandin-independent mechanism in rat gastric mucosa. Arzneimittelforschung. 1992;42:1462-6.
3. Murakami K, Okajima K, Uchiba M. Rebamipide attenuates indomethacin-induced gastric mucosal lesion formation by inhibiting activation of leukocytes in rats. Dig Dis Sci. 1997;42:319-25.
4. Yoshida N, Yoshikawa T, Iinuma S. Rebamipide protects against activation of neutrophils by Helicobacter pylori. Dig Dis Sci. 1996;41:1139-44.
5. Urashima H, Takeji Y, Okamoto T. Rebamipide increases mucin-like substance contents and periodic acid Schiff reagent-positive cells density in normal rabbits. J Ocul Pharmacol Ther. 2012;28:264-70.
6. Kinoshita S, Awamura S, Nakamichi N. A multicenter, open-label, 52-week study of 2% rebamipide (OPC-12759) ophthalmic suspension in patients with dry eye. Am J Ophthalmol. 2014;157:576-83.e1.
7. Kinoshita S, Awamura S, Oshiden K. Rebamipide (OPC-12759) in the treatment of dry eye: a randomized, double-masked, multicenter, placebo-controlled phase II study. Ophthalmology. 2012;119:2471-8.
8. Kinoshita S, Oshiden K, Awamura S. A randomized, multicenter phase 3 study comparing 2% rebamipide (OPC-12759) with 0.1% sodium hyaluronate in the treatment of dry eye. Ophthalmology. 2013;120:1158-65.
9. Suzuki S, Goto E, Dogru M.Tear film lipid layer alterations in allergic conjunctivitis. Cornea. 2006;25:277-80.
10. Toda I, Shimazaki J, Tsubota K. Dry eye with only decreased tear break-up time is sometimes associated with allergic conjunctivitis. Ophthalmology. 1995;102:302-9.
11. Mantelli F, Argüeso P. Functions of ocular surface mucins in health and disease. Curr Opin Allergy Clin Immunol. 2008;8:477-83.
12. Takeji Y, Nakashima H, Kagawa Y. Effect of rebamipide 2% ophthalmic suspension on capsaicin-induced corneal epithelial damage in rats. Atarashii Ganka. 2013;30:1309-13.
13. Ríos JD, Shatos M, Urashima H. OPC-12759 increases the proliferation of cultured rat conjunctival goblet cells. Cornea. 2006;25:573-81.
14. Ríos JD, Shatos MA, Urashima H. Effect of OPC-12759 on EGF receptor activation, p44/p42 MAPK activity and secretion in conjunctival goblet cells. Exp Eye Res. 2008;86:629-36.
15. Takeji Y, Urashima H, Aoki A. Rebamipide 2% increases the mucin-like glycoprotein production in corneal epithelial cells. J Ocul Pharmacol Ther. 2012;28:259-63.
16. Urashima H, Okamoto T, Takeji Y. Rebamipide 2% increases the amount of mucin-like substances on the conjunctiva and cornea in the N-acetylcysteine-treated in vivo model. Cornea. 2004;23:613-9.
17. Ríos JD, Shatos M, Urashima H. OPC-12759 increases the proliferation of cultured rat conjunctival goblet cells. Cornea. 2006;25:573-81.
18. Takeji Y, Urashima H, Aoki A. Rebamipide 2% increases the mucin-like glycoprotein production in corneal epithelial cells. J Ocul Pharmacol Ther. 2012;28:259-63.
19. Kimura K, Morita Y, Orita T.Protection of human corneal epithelial cells from TNF-alpha-induced disruption of barrier function by rebamipide. Invest Ophthalmol Vis Sci. 2013;54:2572-6.
20. Tanka H, Fukuda K, Ishida W. Rebamipide increases barrier function and attenuates TNF-alpha-induced barrier disruption and cytokine expression in human corneal epithelial cells. Br J Ophthalmol. 2013;97:912-6.
21. Ueta M, Sotozono C, Yokoi N. Rebamipide suppresses PolyI:C-stimulated cytokine production in human conjunctival epithelial cells. J Ocul Pharmacol Ther. 2013;29:688-93.
22. Ueta M, Sotozono C, Koga A. Usefulness of a new therapy using rebamipide eyedrops in patients with VKC/AKC refractory to conventional anti-allergic treatments. Allergol Int. 2014;63:75-81.
23. Kumar S. Vernal keratoconjunctivitis: A major review. Acta Ophthalmol. 2009;87(2):133-47.
24. De Smedt S, Wildner G, Kestelyn P. Vernal keratoconjunctivitis: an update. Br J Ophthalmol. 2013;97(1):9-14.
25. Kanski J, Bowling B. Clinical ophthalmology: a systemic approach. 8^th 2016 144-5.
26. Allansmith MR. Vernal conjunctivitis. Clin Ophthalmol. 1986;4:9.
27. Jun J, Bielory L, Raizman MB. Vernal conjunctivitis. Immunol Allergy Clin North Am. 2008;28(1):59-82.
28. Secchi AG, Tognon MS, Leonardi A. Topical use of cyclosporine in the treatment of vernal keratoconjunctivitis. Am J Ophthalmol. 1990;110(6):641-5.
29. Centofeuti M, Shiavone M, Lambaise A. Efficacy of miprogoside ophthalmic gel in vernal keratoconjunctivitis. Eye. 1996;24(4):107-11.
30. Dhawan M, Hans T, Singh B. Rebamipide 2% ophthalmic suspension for the treatment of allergic keratoconjunctivitis: A hospital based study. Delhi J Ophthalmol. 2016;26:246-9.
31. Wong AH, Barg SS, Leung AK. Seasonal and perennial allergic conjunctivitis. Recent Pat Inflamm Allergy Drug Discov. 2014;8:139-53.
32. Leonardi A. Management of vernal keratoconjunctivitis. Ophthalmol Ther. 2013;2:73-88.
33. Chigbu DI, Labib BA. Immunopharmacology in vernal keratoconjunctivitis: Current and future perspectives. Pharmaceuticals. 2021;14(7):658.
34. Singhal D, Sahay P, Maharana PK. Vernal keratoconjunctivitis. Surv Ophthalmol. 2019;64:289-311.
35. Swamy BN, Chilov M, McClellan K. Topical non-steroidal anti-inflammatory drugs in allergic conjunctivitis: Meta-analysis of randomized trial data. Ophthalmic Epidemiol. 2007;14:311-9.
36. Leonardi A, Silva D, Perez Formigo D. Management of ocular allergy. Allergy. 2019;74:1611-30.
37. Al-Amri AM, Fiorentini SF, Albarry MA. Long-term use of 0.003% tacrolimus suspension for treatment of vernal keratoconjunctivitis. Oman J Ophthalmol. 2017;10:145-9.
38. Fukushima A, Ohashi Y, Ebihara N. Therapeutic effects of 0.1% tacrolimus eye drops for refractory allergic ocular diseases with proliferative lesion or corneal involvement. Br J Ophthalmol. 2014;98:1023-7.
39. Hirota A, Shoji J, Inada N. Evaluation of clinical efficacy and safety of prolonged treatment of vernal and atopic keratoconjunctivitis using topical tacrolimus. Cornea. 2022;41:23-30.
40. Müller EG, Santos MSD, Freitas D. Tacrolimus eye drops as monotherapy for vernal keratoconjunctivitis: a randomized controlled trial. Arq Bras Oftalmol. 2017;80:154-8.
41. Pucci N, Caputo R, di Grande L. Tacrolimus vs. cyclosporine eyedrops in severe cyclosporine-resistant vernal keratoconjunctivitis: a randomized, comparative, double-blind, crossover study. Pediatr Allergy Immunol. 2015;26:256-61.
42. Wan Q, Tang J, Han Y. Therapeutic effect of 0.1% tacrolimus eye drops in the tarsal form of vernal keratoconjunctivitis. Ophthalmic Res. 2018;59:126-34.
43. Zanjani H, Aminifard MN, Ghafourian A. Comparative evaluation of tacrolimus versus interferon alpha-2b eye drops in the treatment of vernal keratoconjunctivitis: a randomized, double-masked study. Cornea. 2017;36:675-8.
44. Zhao M, He F, Yang Y.Therapeutic efficacy of tacrolimus in vernal keratoconjunctivitis: A meta-analysis of randomized controlled trials. Eur J Hosp Pharm. 2022;29:129-33.
45. Dupuis P, Prokopich CL, Hynes A.A contemporary look at allergic conjunctivitis. Allergy Asthma Clin Immunol. 2020;16:5.
46. Agnihotri G, Shi K, Lio PA. A clinician’s guide to the recognition and management of dupilumab-associated conjunctivitis. Drugs RandD. 2019;19:311-8.
47. Chigbu DI, Labib BA. Immunopharmacology in vernal keratoconjunctivitis: Current and future perspectives. Pharmaceuticals. 2021;14(7):658.
48. Maudinet A, Law-Koune S, Duretz C. Ocular surface diseases induced by dupilumab in severe atopic dermatitis. Ophthalmol Ther. 2019;8:485-90.
49. Popiela MZ, Barbara R, Turnbull AMJ. Dupilumab-associated ocular surface disease: presentation, management and long-term sequelae. Eye. 2021;35:3277-84.
50. Chen J, Bielory L. Ocular allergic surface disease symptoms associated with atopic keratoconjunctivitis (AKC) alleviated with dupilumab. J Allergy Clin Immunol. 2022;149:AB216.
51. Fukuda K, Ebihara N, Kishimoto T. Amelioration of conjunctival giant papillae by dupilumab in patients with atopic keratoconjunctivitis. J Allergy Clin Immunol Pract. 2020;8:1152-5.
52. Tsui MC, Chiang BL, Wang IJ. Successful treatment and prevention of the recurrence of refractory vernal keratoconjunctivitis with dupilumab. Clin Exp Ophthalmol. 2022;50:1100-3.
53. Roufosse F. Targeting the interleukin-5 pathway for the treatment of eosinophilic conditions other than asthma. Front Med. 2018;5:49.
54. Gatta A, Della Valle L, Farinelli A. Vernal keratoconjunctivitis: a case of anti-IgE treatment with short-lasting remission. Case Rep Ophthalmol. 2020;11:268-75.
55. Zengarini C, Roda M, Schiavi C. Successful treatment of severe recalcitrant vernal keratoconjunctivitis and atopic dermatitis associated with elevated IgE levels with omalizumab. Clin Exp Dermatol. 2021:604-6.
56. Koh S, Inoue Y, Sugimoto T. Effect of rebamipide ophthalmic suspension on optical quality in the short break-up time type of dry eye. Cornea. 2013;32(9):1219-23.
57. Takahashi Y, Ichinose A, Kakizaki H. Topical rebamipide treatment for superior limbic keratoconjunctivitis in patients with thyroid eye disease. Am J Ophthalmol. 2014;157(4):807-12.
58. Itakura H, Kashima T, Itakura M. Topical rebamipide improves lid wiper epitheliopathy. Clin Ophthalmol. 2013;7:2137-41.
59. Kashima T, Akiyama H, Miura F. Resolution of persistent corneal erosion after administration of topical rebamipide. Clin Ophthalmol. 2012;6:1403-6.
60. Cennamo GL, Del Prete A, Forte R. Impression cytology with scanning electron microscopy: A new method in the study of conjunctival microvilli. Eye (Lond). 2008;22(1):138-43.