PURPOSE: Vernal keratoconjunctivitis (VKC) is associated with T-helper 2 (TH2)-like cell response and increased immunoglobulin (Ig) E production. Recent studies have suggested that interactions between costimulatory molecules B7 on antigen-presenting cells and CD28 on T cells are critical for successful antigen presentation and the development of the TH2 immune response. The objective of this study was to examine the expression of costimulatory molecules CD28, B7-1 (CD80) and B7-2 (CD86) in conjunctival biopsies from patients with active VKC and normal controls. METHODS: Conjunctival biopsy specimens from 15 subjects with active VKC, and 8 control subjects, were studied by immunohistochemical techniques using a panel of monoclonal and polyclonal antibodies directed against CD28, B7-1 and B7-2 molecules. The phenotype of inflammatory cells expressing costimulatory molecules was examined by sequential double immunohistochemistry. RESULTS: In the normal conjunctiva, B7-2 was expressed on a few mononuclear cells in the epithelium and substantia propria in 5 of 8 specimens. There was no immunoreactivity for CD28 or B7-1. In VKC specimens, few B7-1+ mononuclear cells were noted in the substantia propria in 7 of 15 specimens. B7-2 was expressed on mononuclear cells in the epithelium and substantia propria in all specimens. Compared with normal controls, VKC specimens showed significantly more mononuclear cells expressing B7-2 (30.5+/-14.1 vs 1.88+/-2.5; p < 0.001). In VKC specimens, the numbers of mononuclear cells expressing B7-2 were significantly higher than the numbers of mononuclear cells expressing B7-1 (30.5+/-14.1 vs 2.3+/-3.1; p < 0.001). CD28 was expressed on mononuclear cells in the epithelium and substantia propria in 14 specimens. Colocalisation studies revealed that the majority of mononuclear cells expressing B7-2 were CD1a+ Langerhans' cells, and that the mononuclear cells expressing CD28 were CD3+ T lymphocytes. CONCLUSIONS: B7-2 is more widely and prominently expressed by Langerhans' cells compared with B7-1. The interaction of B7-2 with CD28 may mediate the development of the TH2 immune response in VKC. Thus the manipulation of this pathway could be an important target for the development of future therapies in VKC.