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Di Zazzo A, Zhu AY, Nischal K, Fung SSM. Vernal keratoconjunctivitis in adults: a narrative review of prevalence, pathogenesis, and management. FRONTIERS IN OPHTHALMOLOGY 2024; 4:1328953. [PMID: 38984145 PMCID: PMC11182140 DOI: 10.3389/fopht.2024.1328953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/29/2024] [Indexed: 07/11/2024]
Abstract
Vernal keratoconjunctivitis (VKC) is a chronic, progressive, allergic ocular surface disorder that can lead to sight-threatening complications. VKC occurs primarily in children and generally resolves about the time of puberty; however, case series and retrospective analyses indicate that approximately 10% of patients with VKC are adults, and that a subset of adult cases develop after puberty. Consequently, two age-related variants of VKC have recently been described: early-onset VKC-which manifests during childhood and persists into adult life-and late-onset disease, which emerges de novo after puberty. Although the signs and symptoms of adult and childhood VKC are similar, adult VKC is a long-lasting disease characterized by severe inflammation and increased risk of conjunctival fibrosis, which may place adult patients at higher risk for sight-threatening complications and adverse impacts on daily life. This review discusses the epidemiology, signs, symptoms, immunopathogenesis of adult VKC variants, and highlights current gaps in research and management of patients with this condition.
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Affiliation(s)
- Antonio Di Zazzo
- Ophthalmology Operative Complex Unit, University Campus Bio-Medico, Rome, Italy
| | - Angela Y Zhu
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Ken Nischal
- Department of Ophthalmology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Simon S M Fung
- Pediatric Ophthalmology, UCLA Stein Eye Institute, Los Angeles, CA, United States
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Ali W, Alam Khan S, Ullah Khan F, Khan S, Khan WA, Zafar R, Moqeet MA. Long-Term Clinical Outcome of Tacrolimus Skin Ointment (0.03%) for the Treatment of Vernal Keratoconjunctivitis: A Quasi-Experimental Study. Cureus 2023; 15:e50579. [PMID: 38226116 PMCID: PMC10788690 DOI: 10.7759/cureus.50579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 01/17/2024] Open
Abstract
Background Vernal keratoconjunctivitis (VKC) is an allergic conjunctival inflammation with severe ocular complications if left untreated. The current management regimen is plagued with adverse effects, long-term problems, and clinical relapses. Tacrolimus offers an alternative treatment option, and long-term studies are needed to determine its efficacy. Methods A two-year follow-up based study was conducted on moderate to severe VKC patients, who were prescribed tacrolimus skin ointment. The 5-5-5 exacerbation scale was used for the monitoring and grading severity of the disease. Analysis of variance (ANOVA) and intergroup comparisons were conducted on exacerbation scale scores among follow-ups. Results A significant reduction was observed in the total score of severity from baseline (203.17±102.05) to three months' follow-up (69.94±70.54), and it kept reducing for 18 months post therapy. Similar results with statistically significant reduction were observed for all grades of the scale. The relapse rate was 5.71% within a month after therapy cessation, and none of the other patients showed relapse afterward. No significant ocular and systemic complications were observed during the study. Conclusion Tacrolimus is effective in the long-term management of VKC without the complications of conventional steroid-based therapy.
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Affiliation(s)
- Warda Ali
- Cornea and Refractive Surgery, Al-Shifa Trust Eye Hospital, Rawalpindi, PAK
| | - Saad Alam Khan
- Cornea and Refractive Surgery, Al-Shifa Trust Eye Hospital, Rawalpindi, PAK
| | - Fahim Ullah Khan
- Cornea and Refractive Surgery, Al-Shifa Trust Eye Hospital, Rawalpindi, PAK
| | - Shama Khan
- Cornea and Refractive Surgery, Al-Shifa Trust Eye Hospital, Rawalpindi, PAK
| | - Wajid A Khan
- Cornea and Refractive Surgery, Al-Shifa Trust Eye Hospital, Rawalpindi, PAK
| | - Rabeeah Zafar
- Cornea and Refractive Surgery, Al-Shifa Trust Eye Hospital, Rawalpindi, PAK
| | - Muhammad A Moqeet
- Cornea and Refractive Surgery, Al-Shifa Trust Eye Hospital, Rawalpindi, PAK
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Ali A, Bielory L, Dotchin S, Hamel P, Strube YNJ, Koo EB. Management of vernal keratoconjunctivitis: Navigating a changing treatment landscape. Surv Ophthalmol 2023:S0039-6257(23)00138-8. [PMID: 37890678 DOI: 10.1016/j.survophthal.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/12/2023] [Accepted: 10/15/2023] [Indexed: 10/29/2023]
Abstract
Vernal keratoconjunctivitis (VKC) is a chronic, progressive, and potentially sight-threatening form of ocular inflammatory disease that primarily affects children and young adults. Prevalence varies by region, ranging from <2 per 10,000 in the United States to as high as 1,100 per 10,000 in parts of Africa. The rarity of VKC in developed countries can make differential diagnosis challenging, and treatment is often delayed until the disease is advanced, and symptoms are significantly impacting patients' quality of life. Although once viewed primarily as an immunoglobulin E-mediated condition, approximately 50% of patients with VKC do not exhibit allergic sensitization. It is now recognized that the immunopathology of VKC involves multiple inflammatory pathways that lead to the signs, symptoms, and conjunctival eosinophilic and fibroproliferative lesions that are a hallmark of the disease. We examine the evolution of our understanding of the immunopathology of VKC, the expanding VKC treatment armamentarium, the clinical implications of emerging treatment approaches, and future directions for VKC research and practice.
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Affiliation(s)
- Asim Ali
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Leonard Bielory
- Departments of Medicine, Allergy, Immunology and Ophthalmology, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Stephanie Dotchin
- Department of Surgery, Section of Ophthalmology, University of Calgary, Calgary, Alberta, Canada
| | - Patrick Hamel
- CHU Ste-Justine, Université de Montréal and McGill University Health Center, Montréal, Québec, Canada
| | - Yi Ning J Strube
- Department of Ophthalmology, Queen's University/Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Euna B Koo
- Stanford Byers Eye Institute, Palo Alto, California, USA
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Leonardi A, Righetti G, Giovannini G, De Marchi V, Occhiuto M. Diagnostic criteria of chronic conjunctivitis: atopic keratoconjunctivitis and vernal keratoconjunctivitis. Curr Opin Allergy Clin Immunol 2023; 23:390-396. [PMID: 37284778 DOI: 10.1097/aci.0000000000000915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE OF REVIEW Chronic ocular allergies, vernal (VKC) and atopic keratoconjunctivitis (AKC) are relatively rare conditions that require definite diagnostic criteria to the most appropriate therapeutical approach. RECENT FINDINGS The diagnosis of both VKC and AKC is generally based on clinical history, signs and symptoms, and the results of allergic tests, which allow to identify the different diseases phenotypes. However, other subtypes of the two diseases and/or overlaps may occur making the diagnosis non always so clear, such as VKC and AKC overlaps or adult-like VKC disease. Each of these phenotypes may be sustained by different mechanisms which are still not well defined but not only related to a type 2 inflammation. The further challenges will be to correlate clinical or molecular biomarkers to a single subtype or disease severity. SUMMARY Definite criteria of chronic allergies will further guide to more specific therapeutical approaches.
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Affiliation(s)
- Andrea Leonardi
- Department of Neuroscience, Ophthalmology Unit, University of Padua, Padua, Italy
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Micera A, Di Zazzo A, De Piano M, Sharma S, Mori T, De Gregorio C, Coassin M, Fernandes M. Tissue remodeling in adult vernal keratoconjunctivitis. Exp Eye Res 2022; 225:109301. [PMID: 36336099 DOI: 10.1016/j.exer.2022.109301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/30/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
Our aim is to describe local tissue remodeling in a cohort of adult VKC patients. Male patients diagnosed with active VKC were enrolled in an open pilot study into two groups according disease onset: childhood classic VKC and adult VKC. Visual acuity and ocular surface clinical examination focusing on chronic inflammatory sequelae and impression cytology were performed in all enrolled subjects. Conjunctival imprints were processed for molecular, biochemical and immunofluorescent analysis for tissue remodeling (TGFβ1,2,3 and αSMA) and epigenetic (DNMT3a, Keap1; Nrf2) markers as well as androgen receptors were investigated and compared between groups. Clinical assessment showed increased conjunctival scarring in adult VKC compared to classic VKC. Immunoreactivity for αSMA and expression of TGFβ were higher in adult VKC group. Significantly higher levels of TGFβ3 (3.44 ± 1.66; p < 0.05) were detected in adult VKC compared to childhood VKC, associated with an increasing trend of TGFβ1 (1.58 ± 0.25) and TGFβ2 (1.65 ± 0.20) isoforms levels. Molecular analysis showed a relative increase in tissue remodeling/fibrogenic transcripts (TGFβ isoforms and αSMA) associated to a significant increase of selective epigenetic targets (DNMT3, Nrf2 and keap1) in adult VKC phenotype. Increased local conjunctival androgen receptors was detected in patients with adult variants compared to classic childhood VKC and healthy subjects. Finally, a direct correlation between TGFβ and androgen receptor expression was also detected. A pro-fibrotic clinical and biomolecular trait was unveiled in adult variant of VKC, which causes ocular surface disease and visual impairment.
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Affiliation(s)
- Alessandra Micera
- Research and Development Laboratory for Biochemical, Molecular and Cellular Applications in Ophthalmological Sciences, IRCCS - Fondazione Bietti, Rome, Italy
| | - Antonio Di Zazzo
- Ophthalmology Operative Complex Unit, University Campus Bio-Medico, Rome, Italy
| | - Maria De Piano
- Research and Development Laboratory for Biochemical, Molecular and Cellular Applications in Ophthalmological Sciences, IRCCS - Fondazione Bietti, Rome, Italy
| | - Savitri Sharma
- Jhaveri Microbiology Centre, LV Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India
| | - Tommaso Mori
- Ophthalmology Operative Complex Unit, University Campus Bio-Medico, Rome, Italy
| | - Chiara De Gregorio
- Ophthalmology Operative Complex Unit, University Campus Bio-Medico, Rome, Italy
| | - Marco Coassin
- Ophthalmology Operative Complex Unit, University Campus Bio-Medico, Rome, Italy
| | - Merle Fernandes
- Cornea and Anterior Segment Services, LV Prasad Eye Institute, GMR Varalakshmi Campus, Visakhapatnam, India.
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Mehta JS, Chen WL, Cheng ACK, Cung LX, Dualan IJ, Kekunnaya R, Khaliddin N, Kim TI, Lam DK, Leo SW, Manurung F, Tesavibul N, Bremond-Gignac D. Diagnosis, Management, and Treatment of Vernal Keratoconjunctivitis in Asia: Recommendations From the Management of Vernal Keratoconjunctivitis in Asia Expert Working Group. Front Med (Lausanne) 2022; 9:882240. [PMID: 35979210 PMCID: PMC9376221 DOI: 10.3389/fmed.2022.882240] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
Vernal keratoconjunctivitis (VKC) is an underdiagnosed and underrecognized ocular surface disease with limited epidemiological data in Asia. It is more prevalent in warm, dry, and windy climates, and often has a substantial impact on a patient's quality of life. In rare cases, VKC can be associated with vision loss, either through corticosteroid overuse or inadequate treatment of persistent inflammation. As a potentially severe and complex disease, there is variability with how VKC is managed across Asia and among the various allergic eye diseases. Diagnosis and treatment of patients with VKC is a challenge for many ophthalmologists, since no precise diagnostic criteria have been established, the pathogenesis of the disease is unclear, and anti-allergic treatments are often ineffective in patients with moderate or severe disease. In addition, the choice of treatment and management strategies used for patients varies greatly from country to country and physician to physician. This may be because of a lack of well-defined, standardized guidelines. In response, the Management of Vernal Keratoconjunctivitis in Asia (MOVIA) Expert Working Group (13 experts) completed a consensus program to evaluate, review, and develop best-practice recommendations for the assessment, diagnosis, and management of VKC in Asia. The expert-led recommendations are summarized in this article and based on the currently available evidence alongside the clinical expertise of ophthalmologists from across Asia with specialism and interest in the ocular surface, VKC, and pediatric ophthalmology.
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Affiliation(s)
- Jodhbir S. Mehta
- Corneal & External Eye Disease Department, Singapore National Eye Centre, Singapore, Singapore
| | - Wei-Li Chen
- Department of Ophthalmology and Advanced Ocular Surface and Corneal Nerve Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Arthur C. K. Cheng
- Department of Ophthalmology, Hong Kong Sanatorium & Hospital, Hong Kong, Hong Kong SAR, China
| | | | - Ivo J. Dualan
- Department of Ophthalmology and Visual Sciences, University of the Philippines, Quezon City, Philippines
| | - Ramesh Kekunnaya
- Child Sight Institute, Jasti V Ramanamma Children’s Eye Care Center, LV Prasad Eye Institute, Hyderabad, India
| | - Nurliza Khaliddin
- Department of Ophthalmology, University Malaya Eye Research Center, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Tae-Im Kim
- Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Douglas K. Lam
- The Hong Kong Ophthalmic Associates, Hong Kong, Hong Kong SAR, China
| | - Seo Wei Leo
- Dr Leo Adult & Paediatric Eye Specialist Pte Ltd; Mount Elizabeth Hospital, Singapore, Singapore
| | | | - Nattaporn Tesavibul
- Department of Ophthalmology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Dominique Bremond-Gignac
- Department of Ophthalmology, University Hospital Necker-Enfants Malades, APHP, OPHTARA, Paris, France; INSERM Unit UMRS1138, Team 17, Paris University, Paris, France
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Understanding Vernal Keratoconjunctivitis: Beyond Allergic Mechanisms. Life (Basel) 2021; 11:life11101012. [PMID: 34685384 PMCID: PMC8541022 DOI: 10.3390/life11101012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/18/2021] [Accepted: 09/23/2021] [Indexed: 12/29/2022] Open
Abstract
Vernal keratoconjunctivitis (VKC) is a chronic, recurrent, inflammatory disease of the cornea and conjunctiva mostly affecting boys in prepubertal age. VKC recurrence is characterized by intense symptoms of itching, redness, and photophobia associated with corneal damage, impairment of visual function, and quality of life. The pathogenesis of VKC has not yet been completely understood, and it is still controversial. In fact, VKC is considered an ocular allergic disease due to the involvement of immunoglobulin E, eosinophils, and mast cells, and of a lymphocyte T-helper type 2 reaction. However, approximately half of VKC patients have negative allergological history and testing, suggesting that other pathogenic mechanisms participate in VKC development and severity. Specifically, evidence suggests that genetic, endocrine, neuronal factors and an imbalance of innate immunity are involved in the pathogenesis of VKC. The purpose of this review is to summarize evidence on the pathogenic role of innate immunity, neuroimmune reaction, and hormonal changes in VKC. Increasing understanding of the pathogenic mechanisms behind VKC may lead to the identification of novel biomarkers for diagnosis and/or potential therapeutic targets in order to improve the management of this challenging condition.
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Abstract
PURPOSE OF REVIEW Vernal keratoconjunctivitis (VKC) is a rare chronic self-limiting allergic inflammatory disease of the ocular surface mostly affecting young boys in their first decade of life. In the last few years a new clinical entity of VKC has been described: adult VKC. Two variants have been identified according to clinical onset: early (childhood VKC persisting beyond puberty) and late onset (arising de novo in adults) adult VKC. Several epidemiologic studies on VKC have been published from single tertiary centers but while the age distribution of VKC patients does show a small percentage of adults with the disease, detailed analysis on this small subset of adult VKC cases is lacking. In this review we describe pathogenesis, clinical features, diagnostic alternatives, and therapeutic alternatives of this highly invalidating disease. RECENT FINDINGS Adult variants of VKC have same clinical manifestations of classic form, but show higher inflammatory response and increased risk of chronic fibrotic sequelae. SUMMARY Adult VKC research could provide insights on the impact of sex hormones in the pathogenesis of allergic diseases and on the mechanisms of inflammation and fibrosis, which cause potentially vision threatening sequelae. The present review will highlight the recent developments in our understanding of this uncommon entity.
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Allergic conjunctivitis in children: current understanding and future perspectives. Curr Opin Allergy Clin Immunol 2020; 20:507-515. [DOI: 10.1097/aci.0000000000000675] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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