Tailored approach to the treatment of vernal keratoconjunctivitis

Unraveling the complexity - Insights and interventions of refractory vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a chronic severe ocular allergic inflammation mostly observed in children and young adults. The ocular manifestations are the expression of multifactorial immune mechanisms that generally have a good prognosis, however long-term inflammation may remarkably reduce the visual function due to complications and poor therapeutic responses. Lack of responsiveness to a drug or treatment is relatively common in VKC and it is not only due to corneal involvement, which is considered the main sign of severity. The concept of refractory may be relative to multiple factors including the clinical condition, systemic co-morbidities, previous or concomitant drugs or regiments, compliance, patient's psychological condition or expectations, type of exposome and environmental conditions, doctor's experience and expectations, or timing of clinical evaluation. In this narrative review, the authors propose a definition of refractory VKC based on revised literature and clinical experience and consider potential new treatments for refractory patients and surgical management in case of complications.

Efficacy of a Cationic Emulsion of Cyclosporine in Moderate Vernal Keratoconjunctivitis

PURPOSE

The aim of this study was to demonstrate the efficacy of cyclosporine A 0.1% cationic emulsion (CsA CE) eye drops 4 times a day in pediatric patients affected by a moderate form of vernal keratoconjunctivitis (VKC).

METHODS

This was a prospective study of pediatric patients, aged 5-16 years, with an active moderate form of VKC who were poor responders to topical antihistamines treatment and were treated 4 times a day with CsA CE. The clinical signs were graded for analysis as follows: hyperemia, tarsal papillae, and limbal papillae.

RESULTS

Twenty-eight patients (22 males and 6 females) with a minimum follow-up period of 3 months were included in the analysis. Statistical analysis excluded tarsal papillae because of the very low baseline value. The clinical score of hyperemia and limbal papillae improved from the first evaluation and was maintained over the follow-up. No side effects were noted.

CONCLUSION

CsA CE has been proposed as a treatment for severe forms of VKC. This study has shown that administration 4 times a day is also effective in the treatment of moderate forms of VKC in children.

Corneal topometric indices and proclivity toward corneal ectasia in vernal keratoconjunctivitis

PURPOSE

To investigate changes in topometric corneal indices and proclivity toward corneal ectasia, as well as keratometric indices and anterior chamber dimensions in palpebral vernal keratoconjunctivitis (VKC).

METHODS

This study included 80 patients with clinically established symptoms of grade 0 or grade 1 palpebral VKC (group 1) and 66 healthy participants (group 2). After a comprehensive ophthalmic examination including best-corrected visual acuity, intraocular pressure measurements and slit-lamp biomicroscopy, pachymetric indices and anterior chamber dimensions were measured using the Pentacam HR rotating Scheimpflug device. Topometric indices, which are particularly useful for determining proclivity toward corneal ectasia, were extracted from a topometric map.

RESULTS

In groups 1 and 2, the mean ages were 13.11±5.22 and 16.45±5.09 years, respectively. The mean age at disease onset in group 1 was 10.09±5.03 years, and the mean disease duration was 36.23±8.43 months. Group 1 had significantly higher mean topometric indices than group 2, particularly the index of surface variance (P=0.001), index of vertical asymmetry (P=0.007), center keratoconus index (P=0.050), and Belin/Ambrosio enhanced ectasia total deviation value (P=0.032). Mean posterior corneal astigmatism differed significantly between groups 1 and 2 (P=0.003).

CONCLUSIONS

Significantly higher mean topometric indices in VKC indicate a proclivity for corneal ectasia, which could be attributed to general changes in the corneal ultrastructure caused by persistent itching-induced eye rubbing.

Efficacy and Satisfaction of Cyclosporine 0.1% in Patients with Vernal Keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a severe form of ocular allergy that compromises the quality of life of affected patients. Topical cyclosporine 0.1% cationic emulsion (CsA-CE) has been recently authorized for the treatment of severe VKC. We treated 29 VKC patients with on-label CsA-CE and recorded signs and symptoms, subjective patient's treatment satisfaction and the additional use of topical corticosteroids in case of exacerbations. CsA-CE was effective in reducing signs and symptoms in daily clinical practice. The overall subjective improvement of symptoms, efficacy of the treatment, tolerability to the drug and compliance reached a high level of subjective satisfaction score.55% of treated patients required the additional use of a 3-day course of topical dexamethasone with 1.13 ± 0.81 mean courses/month. In conclusions, VKC patients reported an overall high satisfaction with used the on-label topical CsA-CE with a limited use of additional topical corticosteroid treatment.

Management of vernal keratoconjunctivitis: Navigating a changing treatment landscape

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.

When to start tacrolimus ointment for vernal keratoconjunctivitis? A proposed treatment protocol

PURPOSE

The aim of this study was to compare treatment regimens of tacrolimus and of topical steroids for VKC and suggest a treatment protocol according to our clinical experience.

METHODS

This retrospective, nonrandomized case series enrolled 85 patients with VKC. Patients were classified clinically according to severity (mild, moderate, severe) and were treated according to a suggested protocol. Analysis was made according to treatment received: tacrolimus ointment as first line treatment (tacrolimus 1st line), tacrolimus ointment after topical steroid drops treatment (tacrolimus 2nd line) and topical steroid drops or artificial tears alone (topical steroid and tears group).

RESULTS

Significant improvements in clinical signs and symptoms were achieved under tacrolimus treatment 14 months in the moderate group and 5 months in the severe group. The longest duration of treatment was for tacrolimus 2nd line group (p = 0.031) and the mean number of visits in the clinic was the highest. The mean number of topical treatments per day was higher in the topical steroid and tears group (2.6 times) than in the two tacrolimus groups (1.3 times for both). The mean time needed to achieve disease remission or relief did not differ between the tacrolimus 1st line and 2nd line groups.

CONCLUSION

Tacrolimus treatment is effective and safe for VKC. Tacrolimus as 1st line treatment may be preferred for severe cases, for faster disease remission compared to tacrolimus as 2nd line treatment; and with fewer topical treatments per day compared to topical steroids.

Long Term Outcomes of Surgical Excision of Giant Papillae with Mitomycin C and Amniotic Membrane Transplantation in the Treatment of Refractory Palpebral Vernal Keratoconjunctivitis

Background and Objectives: To report the long-term outcomes of patients with refractory Vernal Keratoconjunctivitis (VKC) who underwent surgical excision of giant papillae (GP) with mitomycin C (MMC) 0.02% and amniotic membrane transplantation (AMT). Materials and Methods: This is a retrospective interventional single-center case series including five eyes of four patients who had refractory, symptomatic VKC with GP, along with corneal shield ulcers and/or punctate epithelial erosions. They underwent surgical excision of GP with MMC 0.02% alone (1 eye) or with MMC 0.02% and AMT (4 eyes). Their long-term visual and surgical outcomes were studied. Results: All subjects were male with bilateral involvement and mean age of presentation 9.8 years. The surgery was uneventful in all cases. Amongst the four eyes which underwent MMC with AMT, only one eye demonstrated papillary regrowth requiring repeat surgery. Postoperative follow-up ranged from 59 to 77 months (median 66 months). Four patients had the best corrected visual acuity (BCVA) >/= 6/9.5. One patient had BCVA 6/15 at the final follow-up due to the presence of anterior corneal stromal scar and poor ocular surface. Conclusions: Surgical excision of GP in combination with MMC and AMT, in refractory VKC, is a good treatment option with better clinical outcomes over a longer follow-up.

Vernal keratoconjunctivitis activity induces decrease of ocular surface CD14, TLR-4 and TLR-9 expression

PURPOSE

CD14 is involved in the modulation of immune reaction via toll-like receptors (TLR) and may influence the development of allergic diseases. The role of CD14 in vernal keratoconjunctivitis (VKC) has not yet been investigated. The aim of this study is to evaluate changes of tear soluble sCD14 and conjunctival CD14, TLR-4 and 9 expression in patients with VKC in the active and quiescent phases.

METHODS

Eighteen patients with VKC during active inflammation (group A, N = 9), in the quiescent phase (group Q, N = 5) and after recovery (group R, N = 4) and 10 healthy subjects were included. Expression of sCD14 in tears and of CD14, TLR-4, and TLR-9 by conjunctival epithelium were evaluated by Western Blot in all groups.

RESULTS

Expression of tear sCD14 and of conjunctival CD14, TLR-4, and TLR-9 was significantly decreased in group A when compared with healthy subjects and with VKC group Q and R. Lower expression of sCD14, CD14, TLR-4, and TLR-9 were significantly correlated with the severity of papillary reaction, while the lower sCD14 was correlated with severity of conjunctival hyperemia.

CONCLUSIONS

Tear sCD14, and conjunctival CD14, TLR4, and TLR-9 decreased during ocular surface inflammatory reaction in patients with VKC. CD14 and TLRs ocular surface evaluation may represent biomarkers of VKC activity and novel therapeutic target.

Understanding Vernal Keratoconjunctivitis: Beyond Allergic Mechanisms

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.

The two-faced effects of nerves and neuropeptides in corneal diseases

Corneal nerves are instrumental to maintain cornea integrity through regulation of key physiological functions such as tear secretion, blink reflex, and neuropeptide turnover. Corneal nerve injury/stimulation can follow many insults including mechanical/chemical trauma, infections and surgeries. Nerve disruption initiates a process named neurogenic inflammation which leads to edema, pain, and recruitment and activation of leukocytes. Interestingly, leukocyte influx in the cornea can further damage nerves by releasing inflammatory mediators-including neuropeptides. The clinical outcome of neuroinflammation can be beneficial or detrimental to corneal integrity. On one side, it ensures prompt wound healing and prevents infections. On the other, prolonged and/or deranged neuroinflammation can permanently disrupt corneal integrity and impair vision. The cornea is an ideal site to study peripheral neuroinflammation and neurogenic inflammation since it receives the highest density of sensory nerves of the entire body. We will review the corneal nerve anatomy and neurochemistry, discuss the beneficial and detrimental effects of neurogenic inflammation in corneal wound healing, inflammatory processes, and pain. We will also examine the emerging remote impact of corneal nerve disruption on the trigeminal ganglion and the brain, highlighting the key role of neuropeptide Substance P. Finally, we will discuss the clinical relevance of such neuroinflammatory network in the context of severe and highly prevalent ocular diseases, including potential treatments.

Corneal and lens densitometry in patients with vernal keratoconjunctivitis

AIM

To evaluate corneal and crystalline lens densitometry in patients with vernal keratoconjunctivitis (VKC).

METHODS

This is a case-control study. Patients with VKC and age-gender-matched healthy controls underwent a complete ophthalmologic examination with corneal and crystalline lens densitometry measurements. Additionally, the anterior chamber parameters comprise anterior and posterior K_mean and astigmatism, anterior chamber depth (ACD), anterior chamber volume (ACV), anterior chamber angle (ACA), pachymeter, and corneal volume (CV). Patients who had clinically grade 0 or grade 1 VKC and with only tarsal conjunctiva involvement during the conductance of the study were included. The variables were compared statistically.

RESULTS

One hundred and nine eyes were included in the study, in which fifty-one were in the VKC group. There were 25 males in the VKC group (26 female) and 22 males in the control group (36 female). A statistically significant difference was found between the groups in terms of posterior corneal astigmatism (p = 0.02). The mean corneal pachymeter, CV, ACD, ACA, and ACV were similar in both groups (p = 0.63, p = 0.26, p = 0.60, p = 0.41, and p = 0.32, respectively). The total mean corneal densitometry in the zones extending from 6 to 10 mm and 10 to 12 mm was increased in the VKC group compared to the control group (p = 0.04 and p = 0.012, respectively). The mean crystalline lens was found to be denser in the VKC group compared to the control group (8.96 ± 1.6 vs. 8.5 ± 0.57, respectively, p = 0.04).

CONCLUSION

Posterior corneal astigmatism is increased in VKC cases in comparison with age- and gender-matched controls. The peripheral anterior 6-12 mm annular corneal zone showed increased corneal densitometry in VKC cases compared to the healthy subjects. Additionally, the lens clarity is found to be decreased subclinically in VKC cases compared to control cases.

High interpretable machine learning classifier for early glaucoma diagnosis

AIM

To develop a classifier for differentiating between healthy and early stage glaucoma eyes based on peripapillary retinal nerve fiber layer (RNFL) thicknesses measured with optical coherence tomography (OCT), using machine learning algorithms with a high interpretability.

METHODS

Ninety patients with early glaucoma and 85 healthy eyes were included. Early glaucoma eyes showed a visual field (VF) defect with mean deviation >-6.00 dB and characteristic glaucomatous morphology. RNFL thickness in every quadrant, clock-hour and average thickness were used to feed machine learning algorithms. Cluster analysis was conducted to detect and exclude outliers. Tree gradient boosting algorithms were used to calculate the importance of parameters on the classifier and to check the relation between their values and its impact on the classifier. Parameters with the lowest importance were excluded and a weighted decision tree analysis was applied to obtain an interpretable classifier. Area under the ROC curve (AUC), accuracy and generalization ability of the model were estimated using cross validation techniques.

RESULTS

Average and 7 clock-hour RNFL thicknesses were the parameters with the highest importance. Correlation between parameter values and impact on classification displayed a stepped pattern for average thickness. Decision tree model revealed that average thickness lower than 82 µm was a high predictor for early glaucoma. Model scores had AUC of 0.953 (95%CI: 0.903-0998), with an accuracy of 89%.

CONCLUSION

Gradient boosting methods provide accurate and highly interpretable classifiers to discriminate between early glaucoma and healthy eyes. Average and 7-hour RNFL thicknesses have the best discriminant power.

Systemic interventions for severe atopic and vernal keratoconjunctivitis in children and young people up to the age of 16 years

BACKGROUND

Atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC) are severe and potentially sight-threatening allergic eye diseases characterised by chronic inflammation of the ocular surface. Both topical and systemic treatments are used. This Cochrane Review focuses on systemic treatments.

OBJECTIVES

To assess the effects of systemic treatments (including corticosteroids, NSAIDS, immunomodulators, and monoclonal antibodies), alone or in combination, compared to placebo or other systemic or topical treatment, for severe AKC and VKC in children and young people up to the age of 16 years.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, Ovid Embase, the ISRCTN registry, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). There were no restrictions to language or year of publication. We last searched the electronic databases on 17 February 2020.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) that involved systemic treatments in children aged up to 16 years with a clinical diagnosis of AKC or VKC. We planned to include studies that evaluated a single systemic medication versus placebo, and studies that compared two or multiple active treatments.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane.

MAIN RESULTS

No trial met the inclusion criteria of this Cochrane Review. No RCTs have been carried out on this topic.

AUTHORS' CONCLUSIONS

There is currently no evidence from randomised controlled trials regarding the safety and efficacy of systemic treatments for VKC and AKC. Trials are required to test efficacy and safety of current and future treatments. Outcome measures need to be developed which can capture both objective clinical and patient-reported aspects of the condition and treatments.

Corneal and lens densitometry with Pentacam HR in children with vernal keratoconjunctivitis

CLINICAL RELEVANCE

Corneal and lens densitometry measurements provide clinically important information for the evaluation and monitoring of corneal and lens health in patients with vernal keratoconjunctivitis.

BACKGROUND

To compare the corneal and lens densitometry values between paediatric patients with vernal keratoconjunctivitis (VKC) and healthy individuals.

METHODS

This study included 72 eyes of 72 patients with VKC (25 with mild VKC [Group 1], 22 with moderate VKC [Group 2], and 25 with severe VKC [Group 3]), and 25 eyes of 25 healthy subjects (Group 4). Corneal and lens densitometry values were measured using Pentacam HR as follows: for corneal densitometry in two different corneal zones (0-2 and 2-6-mm) and four different corneal depths (at the total thickness, anterior, central, and posterior layers), and lens densitometry in three different lens zones (Zone 1: 2.0-mm, Zone 2: 4.0-mm, and Zone 3: 6.0-mm).

RESULTS

In the 0-2-mm corneal zone for the total thickness and all three layers, corneal densitometry values in Group 3 were significantly higher than those in Groups 1, 2, and 4 (for all values p < 0.012). There was no significant difference in the mean corneal densitometry values between Groups 1 and 2 (for all values p > 0.05). In these groups, the mean corneal densitometry values were significantly higher than those in Group 4 for the anterior layer in the 0-2 and 2-6-mm corneal zones (for all values p < 0.012). The mean values for Zone 3 and average lens densitometry values in Groups 2 and 3 were significantly higher than those in Group 4 (p = 0.001 and p = 0.001, respectively).

CONCLUSION

The current study showed corneal clarity changes in patients with mild, moderate, and especially severe VKC. An increase in the lens densitometry values was also observed in patients with moderate and severe VKC than in healthy individuals.

Neurotrophic factors and nerve growth factor in ocular allergy

PURPOSE OF REVIEW

During allergic reaction, nervous and immune systems mutually interact through release of mediators, including neurotrophic factors and nerve growth factor (NGF). These mediators modulate allergic reaction through binding their receptors expressed by immune and structural cells and by stimulating neuropeptide release by nerves. The role of neuropeptides and NGF has been demonstrated in allergic asthma and rhinitis, and, to a lesser extent, in allergic conjunctivitis. The aim of this review are to elucidate the evidence of the role of NGF and neuropeptides in the pathogenesis of allergic conjunctivitis.

RECENT FINDINGS

NGF modulates allergic reaction by stimulating release of cytokines, inflammatory mediators and neuropeptides by immune and structural cells and nerve endings at the site of inflammation. Evidence showed that local and systemic NGF levels increase in patients with allergic conjunctivitis, including allergic rhinoconjuncivitis, vernal keratoconjunctivitis and atopic keratoconjunctivitis. We recently described an increase of conjunctival p75NTR expression in patients with allergic rhinoconjuncivitis, and an increase of tear levels of NGF after conjunctival provocation test with allergen.

SUMMARY

NGF modulates ocular allergic reaction. Increasing understanding of the role of neuropeptides in allergic conjunctivitis may pave the way to the development of novel therapeutic approaches and improvement of patients' management.

Omalizumab in three children with severe vernal keratoconjunctivitis

Background

Vernal keratoconjunctivitis (VKC) is a rare, recurrent form of ocular allergy that can be refractory to topical and systemic treatment. It typically presents as acute and chronic keratoconjunctival inflammation that may lead to visual impairment due to corneal ulcers and scaring. Patients often suffer from atopic IgE-driven comorbidities, especially atopic eczema. Children are frequently affected and often do not tolerate topical treatment well, especially if photophobia and pain impair therapy adherence. We present three children with severe VKC who were not controlled by first- and second-line topical and systemic therapy and finally responded to treatment with the monoclonal anti-IgE antibody omalizumab as third-line treatment.

Methods and results

We retrospectively analyzed three patients with VKC having failed response to first- and second-line treatment. All three boys had very early allergic rhinoconjunctivitis from age 1–3 with polysensitization: birch, grass pollen, house dust mite, and/or pets. All received subcutaneous or sublingual immunotherapy (SCIT/SLIT) for birch and/or grass pollen without major success. Two patients had comorbidities: allergic asthma and severe atopic dermatitis (AD). For at least 6 months after the first administration, monoclonal anti-IgE antibody omalizumab (150 or 300 mg) was administered subcutaneously every 2–6 weeks in all patients achieving improvement of the clinical grading scale from VKC grade 3–4 to grade 1–2. One patient had a relapse mainly of his AD and achieved complete control of AD and VKC by introduction of dupilumab.

Conclusion

Although the clinical benefit of omalizumab in asthma and chronic spontaneous urticaria (CSU) has been established in several clinical trials, there are very little data about its effect on severe VKC. In addition to few previously reported cases we can report the rapid effectiveness of omalizumab in VKC clinically and in terms of quality of life. Randomized trials are needed to include omalizumab in third-line treatment of VKC for prevention of visual impairment and further sequelae such as corneal damage.

Clinical efficacy assessment in severe vernal keratoconjunctivitis: preliminary validation of a new penalties-adjusted corneal fluorescein staining score

Introduction and objective: Vernal keratoconjunctivitis (VKC) is a rare allergic eye condition that occurs in children and is characterised by a combination of debilitating symptoms. Repeated use of topical corticosteroid rescue therapy is often necessary in severe forms. This study aims to assess the validity of a new composite endpoint: the penalties-adjusted corneal staining score (PACS-S) proposed as primary endpoint in VEKTIS trial evaluating the efficacy of a new corticosteroid-sparing treatment, VERKAZIA® (ciclosporin 1 mg/ml eye drops), in severe VKC patients. Methodology: This research comprised a systematic literature review to identify efficacy endpoints being proposed in clinical trials for pediatric patients with severe VKC, followed by a remote expert advisory board assessing the validity of the PACS-S. Results: While no agreed or validated endpoint for assessing efficacy in VKC was identified when VEKTIS trial started, the experts' board acknowledged a high face validity of PACS-S as a subjective integrated measure matching the current clinical practice. A fair external validity was considered with regards to VEKTIS trial secondary endpoints. Conclusion: PACS-S appears to be a reliable, valid and clinically meaningful primary endpoint that allows significant improvement over existing endpoints in severe VKC trials. Additional research is needed to validate this endpoint.

Eye drop emulsion containing 0.1% cyclosporin (1 mg/mL) for the treatment of severe vernal keratoconjunctivitis: an evidence-based review and place in therapy

Vernal keratoconjunctivitis (VKC) is a rare, recurrent and multifactorial ocular disease, which typically flares up during spring and affects especially male children and adolescents. This condition does not usually respond to common treatments with antihistamines or mast cells stabilizers, whereas corticosteroids have effective results. Corticosteroids need to be carefully administered, to avoid adverse effects, mainly the secondary development of glaucoma, cataracts, or infections. Immunosuppressive agents, such as cyclosporin (CyA) or tacrolimus are, therefore, frequently employed in VKC patients. Only the 0.1% CyA (1 mg/mL) concentration has an approved and specific clinical indication for the treatment of VKC and this drug was given the denomination of orphan drug by the European Commission (EU/3/06/360) in 2006. So far, few studies have been conducted to evaluate the efficacy and the side effects of topical 0.1% CyA. Different topical CyA concentrations, ranging from 0.05% to 2%, and various types of formulation are available at the moment. In the future, 0.1% CyA will presumably take an important part in the management of VKC. The present review focuses on eye drops containing 0.1% CyA; however, more studies will be needed to define its long-term efficacy in the natural course of this severe ocular disease.

Allergy screening in a schoolchildren-based population

BACKGROUND

Schoolchildren screening for allergic diseases may improve early identification and management of atopic children. The aim of this study was to perform a schoolchildren screening program for identification of children with allergic diseases.

METHODS

All parents of children attending to 13 primary schools in the city of Rome were requested to fill in a demographic data form and the ChAt questionnaire. Allergological evaluation was performed in the children with suspect of allergy (ChAt score > 2). Ocular examination was performed to identify signs of allergic conjunctivitis. The presence of allergic symptoms was related to demographic and environmental variables.

RESULTS

A total of 2667 children (mean age: 7.1 ± 1 years) were included, and 2489 (93.3%) parents completed the ChAt questionnaire. Results of ChAt questionnaire showed a previous diagnosis of allergic disease in 637 (25.6%) children and the potential presence of an allergic disease (ChAt score > 2) in 35.1%. Multivariate analysis showed that older age, male gender, and having less than two siblings were associated with higher risk of allergic disease. Visual screening showed the presence of clinical signs of allergic conjunctivitis in 2% of children. Allergologic evaluation in 334 children confirmed the diagnosis of allergic disease in 324 (97%) cases. Among them, 97 (29.9%) did not refer to a previous formal diagnosis of allergic condition.

CONCLUSIONS

This study confirmed that schoolchildren screening using ChAt questionnaire could represent a useful tool for early identification of yet undiagnosed atopic children.

Corneal backward scattering and higher-order aberrations in children with vernal keratoconjunctivitis and normal topography

PURPOSE

To investigate the corneal backward scattering and higher-order aberrations (HOAs) in children with vernal keratoconjunctivitis (VKC) and normal topography.

METHODS

Thirty-six eyes of 22 patients with VKC and 54 eyes of 34 normal subjects were included. All participants had clear cornea, absence of dry eyes and a normal corneal tomography. Scheimpflug imaging was used to measure corneal backward scattering in zones centred on the corneal apex (central 2-mm zone and paracentral 2- to 6-mm zone), and HOAs were compared between VKC and normal control.

RESULTS

The mean age of participants was 12.0 ± 4.1 years in VKC group and 11.2 ± 4.1 years in control group (p = 0.339). There was no significant intergroup difference in mean keratometry, astigmatism and apex pachymetry (p ≥ 0.076). Total corneal backscatter was higher in the VKC group compared to the control group (p ≤ 0.012). Anterior and posterior cornea displayed a higher level of backward scattering in the VKC group (p < 0.001 for anterior; p ≤ 0.048 for posterior). Patients with VKC exhibited higher total HOAs and coma (p ≤ 0.036). There were significant correlations between total anterior HOAs and backward scattering measured at the central (r = 0.500; p = 0.032) and paracentral zones (r = 0.470; p = 0.024) for VKC.

CONCLUSION

The current study showed optical quality changes in patients with clear corneas and quiescent VKC. An increase in corneal backward scattering and HOAs was noted in patients with VKC as compared to normal patients.

Corneal staining patterns in vernal keratoconjunctivitis: the new VKC-CLEK scoring scale

AIM

To propose a new scoring system in the assessment of ocular surface epithelial damage in vernal keratoconjunctivitis (VKC).

METHODS

25 consecutive patients with VKC (50 eyes) were evaluated using the Quality of Life in children with VKC (QUICK) questionnaire and objective clinical measures: fluorescein and lissamine green staining and cornea confocal microscopy (Heidelberg Retina Tomography 3). Oxford, Van Bljsterweld and a new system, the VKC-Collaborative Longitudinal Evaluation of Keratoconus study (CLEK) (VKC-CLEK) scores, were used to evaluate the epithelial damage after staining.

RESULTS

Mean Oxford and VKC-CLEK scores were significantly different after fluorescein staining (P<0.001), but significantly correlated (P<0.001; r=0.649). The same data were obtained comparing Van Bljsterweld and VKC-CLEK after lissamine green staining (P<0.001; r=0.760). In patient with limbal VKC, a statistically significant difference was found comparing new VKC-CLEK scores and Oxford or Van Bljsterweld scores (P<0.001), but not in tarsal VKC. A statistically superior concordance was found between QUICK and VKC-CLEK scores compared with standard staining scores values (P<0.001).

CONCLUSIONS

Oxford and Van Bijsterveld scores are not adequate for the evaluation of the epithelial damage in patients with limbal VKC because the staining patterns considered for these tests do not correspond to the staining patterns in patients with VKC. We propose a new scoring system, VKC-CLEK, to better evaluate both limbal and tarsal epithelial damage in patients with VKC.

Vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a chronic allergic conjunctivitis that is most often seen in young, males. Although most types of allergic conjunctivitis do not affect vision, VKC is unusual in that damage to the cornea from the condition can result in vision loss. Although it is typically seasonal, year-round symptoms can be seen, which can lead to uncertain diagnoses being made. Although the pathophysiology of VKC is better understood in recent years, allowing more targeted therapies, management of these patients can still be very challenging, and complications can occur. As such, aggressive management of VKC is necessary, especially since vision loss in the amblyogenic age range can be permanent.

Systematic approach to managing vernal keratoconjunctivitis in clinical practice: Severity grading system and a treatment algorithm

Vernal keratoconjunctivitis is an ocular allergy that is common in the pediatric age group. It is often chronic, severe, and nonresponsive to the available treatment options. Management of these children is difficult and often a dilemma for the practitioner. There is a need to simplify and standardize its management. To achieve this goal, we require a grading system to judge the severity of inflammation and an algorithm to select the appropriate medications. This article provides a simple and practically useful grading system and a stepladder algorithm for systematic treatment of these patients. Use of appropriate treatment modalities can reduce treatment and disease-related complications.

Very Low Prevalence of Keratoconus in a Large Series of Vernal Keratoconjunctivitis Patients

PURPOSE

To evaluate the prevalence of keratoconus (KC) and other corneal abnormalities by means of videokeratography and tomography in a large series of patients affected by vernal keratoconjunctivitis (VKC).

DESIGN

Cross-sectional study.

METHODS

Setting: Single-center children's hospital.

STUDY POPULATION

A total of 651 consecutive patients with VKC and a control group of 500 were prospectively recruited between May 1, 2012 and September 30, 2013, with a minimum follow-up of 12 months.

OBSERVATION PROCEDURE

All patients were evaluated by means of a Scheimpflug camera combined with a Placido corneal topographer. Keratoconus, suspected keratoconus, or its absence were determined in each patient. The corneal symmetry index of front (SI_f) and back curvature (SI_b), shape indices, and thicknesses were compared between the 2 groups.

MAIN OUTCOME MEASURES

Prevalence of keratoconus and corneal indices modifications.

RESULTS

Five out of 651 patients (0.77%) demonstrated topographic signs of KC. Two of them were bilateral. All patients were older than 7 years of age, and the mean age was 11.54 years. Four other patients (0.61%) were classified as KC suspects by the screening program. Of 304 patients older than 11 years (mean age 14.4 years), 4 (1.32%) were found to have KCN, and 4 (1.32%) were KC suspects. The corneal indices of patients in the VKC group were extremely similar to those in the control group. (P > .05).

CONCLUSIONS

The prevalence of KC in our patient population, compared with previous reports in the literature, is much lower. The similar corneal indices in both groups suggest the absence of permanent corneal deformation due to VKC.

Microarray-based IgE detection in tears of patients with vernal keratoconjunctivitis

BACKGROUND

A specific allergen sensitization can be demonstrated in approximately half of the vernal keratoconjunctivitis (VKC) patients by conventional allergic tests. The measurement of specific IgE in tears using a multiplex allergen microarray may offer advantages to identify local sensitization to a specific allergen.

METHODS

In spring-summer 2011, serum and tears samples were collected from 10 active VKC patients (three females, seven males) and 10 age-matched normal subjects. Skin prick test, symptoms score and full ophthalmological examination were performed. Specific serum and tear IgE were assayed using ImmunoCAP ISAC, a microarray containing 103 components derived from 47 allergens.

RESULTS

Normal subjects resulted negative for the presence of specific IgE both in serum and in tears. Of the 10 VKC patients, six resulted positive to specific IgE in serum and/or tears. In three of these six patients, specific IgE was found positive only in tears. Cross-reactivity between specific markers was found in three patients. Grass, tree, mites, animal but also food allergen-specific IgE were found in tears. Conjunctival provocation test performed out of season confirmed the specific local conjunctival reactivity.

CONCLUSIONS

Multiple specific IgE measurements with single protein allergens using a microarray technique in tear samples are a useful, simple and non-invasive diagnostic tool. ImmunoCAP ISAC detects allergen sensitization at component level and adds important information by defining both cross- and co-sensitization to a large variety of allergen molecules. The presence of specific IgE only in tears of VKC patients reinforces the concept of possible local sensitization.

Dry Eye in Vernal Keratoconjunctivitis: A Cross-Sectional Comparative Study

The purpose of this comparative cross-sectional study was to investigate the use of standardized clinical tests for dry eye in pediatric patients with active and quiet vernal keratoconjunctivitis (VKC) and to compare them with healthy children.We recruited 35 active VKC, 35 inactive VKC, and 70 age-matched control healthy subjects. Each child underwent a complete eye examination, including visual analog scale symptoms assessment, biomicroscopy, fluorescein break-up time (BUT), corneal fluorescein and conjunctival lissamine green staining, corneal esthesiometry, Schirmer test with anesthetic, and meibomian glands inspection and expression.Active VKC patients showed significantly increased symptoms and signs of ocular surface disease, compared with the other 2 groups. Inactive VKC patients, compared with control subjects, showed increased photophobia (P < 0.05; Mann-Whitney U test), conjunctival lissamine green staining and Schirmer test values, and reduced BUT and corneal sensitivity [P < 0.05 by analysis of variance (ANOVA) least significant difference posthoc test for BUT and Schirmer; P < 0.001 by Mann-Whitney U test for lissamine green staining and corneal sensitivity].Our results confirm the association between VKC and short-BUT dry eye. This syndrome seems to affect the ocular surface in quiescent phases too, determining abnormalities in tear film stability, epithelial cells integrity, and corneal nerves function. The very long-term consequences of this perennial mechanism of ocular surface damage have not been fully understood yet.

Sex hormones in allergic conjunctivitis: altered levels of circulating androgens and estrogens in children and adolescents with vernal keratoconjunctivitis

Purpose. Vernal keratoconjunctivitis (VKC) is a chronic allergic disease mainly affecting boys in prepubertal age and usually recovering after puberty. To evaluate a possible role of sex hormones in VKC, serum levels of sex hormones in children and adolescents with VKC were assessed. Methods. 12 prepubertal and 7 early pubertal boys with active VKC and 6 male patients with VKC in remission phase at late pubertal age and 48 healthy age and sex-matched subjects were included. Serum concentration of estrone, 17 beta-estradiol, dehydroepiandrosterone-sulfate, total testosterone and free testosterone, dihydrotestosterone (DHT), cortisol, delta-4-androstenedione, follicle-stimulating hormone, luteinizing hormone, and sex-hormones binding globuline (SHBG) were evaluated. Results. Serum levels of Estrone were significantly increased in all groups of patients with VKC when compared to healthy controls (P < 0.001). Prepubertal and early pubertal VKC showed a significant decrease in DHT (P = 0.007 and P = 0.028, resp.) and SHBG (P = 0.01 and P = 0.002, resp.) when compared to controls and serum levels of SHBG were increased in late pubertal VKC in remission phase (P = 0.007). Conclusions and Relevance. VKC patients have different circulating sex hormone levels in different phases of the disease and when compared to nonallergic subjects. These findings suggest a role played by sex hormones in the pathogenesis and/or activity of VKC.

Identification of human tear fluid biomarkers in vernal keratoconjunctivitis using iTRAQ quantitative proteomics

BACKGROUND

Understanding and treating vernal keratoconjunctivitis (VKC) has been a challenge because the pathogenesis is unclear and antiallergic therapy often unsuccessful. The aim of the study was to analyze peptide profiles in human tears using mass spectrometry to elucidate compositional differences between healthy subjects and patients affected by VKC.

METHODS

Tears were collected from healthy subjects and VKC patients. Digested samples were treated with iTRAQ (isobaric tag for relative and absolute quantitation). Separation of tryptic peptides was realized using a MicroHPLC interfaced with a microfraction collector. MS and MS/MS mass spectra were performed using a MALDI TOF/TOF 4800 Applied Biosystem spectrometer. Protein Pilot™ software with Paragon™ algorithm v4.1.46 or GPS™ with Mascot engine was used as search engines with SwissProt or IPI human as the databases.

RESULTS

A significant number of peptides were examined, and 78 proteins were successfully identified. In all VKC samples, levels of serum albumin, transferrin, and hemopexin were found up to 100 times higher than control tear levels and correlated to the severity of disease. Hemopexin, transferrin, mammaglobin B, and secretoglobin 1D were found significantly over-expressed in VKC samples compared with the control samples. Tear samples from patients treated with topical cyclosporine or corticosteroids showed a dramatic reduction in these protein levels.

CONCLUSIONS

LC MALDI MS and isobaric tag for relative and absolute quantitation technique may be useful in the quantitative and qualitative characterization of the peptidoma of human tears. These techniques may identify target proteins to be used in the diagnosis and management of VKC and other inflammatory ocular surface conditions.

Management of vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a relatively rare, chronic form of ocular allergy that can potentially cause severe visual complications. Affecting mainly children and young adults, it is an IgE- and T cell-mediated disease, leading to a chronic inflammation in which eosinophil, lymphocyte and structural cell activation are involved. Treatment of VKC requires a multiple approach that includes conservative measures and pharmacologic treatment. Patients and parents should be made aware of the long duration of disease, its chronic evolution and possible complications. Treatment should be based on the duration and frequency of symptoms and the severity of corneal involvement. Mast cell stabilizers and antihistamines have been proven to be effective for the treatment of mild to moderate forms of VKC. In the most severe cases, topical steroids can be used as rescue medication to reduce conjunctival and corneal inflammation. Immunomodulators that have been investigated for VKC treatment include topical ocular preparations of cyclosporine A and tacrolimus. Topical cyclosporine A has been proven to be effective in the long-term treatment of VKC, significantly improving signs and symptoms without significant side effects.

Ocular manifestations of graft-versus-host disease

Allogeneic hematopoietic stem cell transplantation (HSCT) has evolved over the past two decades to become the standard of care for hematologic and lymphoid malignancies. Major ocular complications after allogeneic HSCT have been increasing in number and severity. Graft-versus-host disease (GVHD) remains a major cause of ocular morbidity after allogeneic HSCT. The main objective of this review is to elucidate the ocular complications in patients developing GVHD following HSCT. Ocular complications secondary to GVHD are common and include dry eye syndrome, acquisition of ocular allergy from donors with allergic disorders. Eyelid changes may occur in GVHD leading to scleroderma-like changes. Patients may develop poliosis, madarosis, vitiligo, lagophthalmos, and entropion. The cornea may show filamentary keratitis, superficial punctate keratitis, corneal ulcers, and peripheral corneal melting which may lead to perforation in severe cases. Scleritis may also occur which can be anterior or posterior. Keratoconjunctivis sicca appears to be the most common presentation of GVHD. The lacrimal glands may be involved with mononuclear cell infiltration of both the major and accessory lacrimal glands and decrease in tear production. Severe dry eye syndrome in patients with GVHD may develop conjunctival scarring, keratinization, and cicatrization of the conjunctiva. Therapy of GVHD includes systemic immunosuppression and local therapy. Surgical treatment in refractory cases includes surgical intervention to improve the manifestation of GVHD of the eye. This may include tarsorrhapy, prose lenses, punctal occlusions and corneal transplantation.

Vernal keratoconjunctivitis-like disease in adults

PURPOSE

To identify clinical, demographic, immunologic, and health-related quality-of-life data from a cohort of vernal keratoconjunctivitis (VKC) patients with the onset of the disease after puberty (VKC-like disease).

DESIGN

Retrospective, observational case series.

METHODS

Forty-nine patients with late-onset VKC-like disease from among 600 consecutive VKC patients. History of disease, test results for allergen sensitivity, signs and symptoms, impact of disease on work productivity, health-related quality of life, and treatment satisfaction were assessed. In addition, multiplex bead analysis for Th1/Th2 cytokines were carried out in tear samples from 20 VKC patients (10 adults and 10 children) and from 10 normal subjects.

RESULTS

A family history of allergy was positive in only 28% and positive prick test results were present in 55% of the 49 VKC-like adult patients. Based on typical signs and symptoms, 48% were affected by the limbal form, 33% were affected by the tarsal form, and 19% were affected by the mixed form. Corneal ulcer complicated the disease in only 2 adult patients. Although the disease was not considered a limiting factor for work, productivity was reduced by 26% and social activities were reduced by 31% during active flare-ups. No significant differences were found in tear cytokine pattern production between VKC in children and VKC in adults.

CONCLUSIONS

A late onset VKC-like disease can appear in young adults with signs and symptoms similar to those in pediatric disease, but with less corneal involvement.

Tratamento homeopático de crianças com úlcera de córnea em escudo por ceratoconjuntivite primaveril: relato de casos e aspectos bioéticos

OBJETIVOS: apresentar um tratamento homeo-pático de úlcera de córnea por ceratoconjuntivite primaveril, considerando-o bioeticamente. MÉTODOS: foram usados nove casos, encami-nhados por insucesso terapêutico convencional. Escolheram-se os medicamentos de acordo com características singularizantes dos pacientes que incluíram o psiquismo. Levantaram-se os custos medicamentosos consultando-se três farmácias homeopáticas e três não-homeopáticas de Belo Horizonte. O tratamento convencional foi estimado a partir da medicação usada pelos enfermos antes do início dos cuidados homeopáticos. RESULTADOS: as cicatrizações ocorreram entre quinze e cento e oitenta dias, com custo medicamentoso médio de oito dólares, cerca de treze vezes menor do que a estimativa de custo direto de um mês da abordagem convencional. O manejo terapêutico da similitude pode minimizar preocupações bioéticas relativas à atenção à saúde de crianças com ceratoconjuntivite primaveril. CONCLUSÕES: a homeopatia pode colaborar para o tratamento desta enfermidade, aprimorando-o bioeticamente.

Surgical Debridement Plus Topical Cyclosporine a in the Treatment and Vernal Shield Ulcers

Vernal Keratoconjunctivitis (VKC) is a severe chronic bilateral inflammation of the ocular surface characterized by seasonal exacerbations. Long-term prognosis is generally good; however, 6% develop sequelae responsible for permanent visual impairment. Corneal involvement is almost always present, consisting of punctate keratitis, shield ulcers (3–11%) and late corneal neovascularization. In recent years, topical cyclosporine A preparations at 2% in oil or at 1% in polyvinyl alcohol, have been successfully proposed for long term VKC treatments. It has been previously proven that medical treatment is not always sufficient, especially when it is employed to treat shield ulcer plaques. In such conditions, surgery may be effective for avoiding long term complications such as amblyopia, strabismus, infections and corneal perforation. In this paper, we show the efficacy of surgical debridement by means of simple scraping associated with topical cyclosporine treatment for the management of vernal shield ulcers complicated with plaques.