Vernal Keratoconjunctivitis

Oral Cyclosporine in Vernal Keratoconjunctivitis: Indications, Outcomes, and Effect on Corticosteroid Use

PURPOSE

The purpose of this study was to report the indications and outcomes of oral cyclosporine A (oCsA) use in vernal keratoconjunctivitis (VKC) and to assess its effect on corticosteroid use.

METHODS

This retrospective review of VKC cases included patients who were prescribed oCsA. Data on clinical characteristics, demographic profile, and treatment were collected. An acute episode was defined as one requiring oral/topical corticosteroids. The outcome measure was the difference in the number of acute episodes before and after oCsA use.

RESULTS

The study included 27 cases (54 eyes) of VKC from 2016 to 2024. The median age was 20 years. Thirty eyes had sequelae due to VKC, the most common of which was limbal stem cell deficiency (46%). The median duration of follow-up was 11 months. Indications for oCsA were recalcitrant disease (23/27, 85%) and severe active allergy in steroid-induced glaucoma/steroid responders (4/27, 15%). None of the cases experienced progression of sequelae with oCsA use. Forty-two acute episodes were observed before oCsA initiation over 403 person-months, which reduced to 10 episodes over 250 person-months with oCsA use. Without oCsA use, the odds of developing an acute exacerbation of the ocular allergy were 2.6 times (95% confidence interval: 1.3-5.2) higher compared with that with oCsA usage.

CONCLUSIONS

Oral cyclosporine reduces corticosteroid use in VKC and can be considered in recalcitrant disease or in eyes with steroid-induced glaucoma and active allergy. Oral cyclosporine significantly reduced the risk of acute exacerbations, proving to be an effective modality for controlling inflammation in VKC.

Tear film parameters and meibography in eyes of children with vernal keratoconjunctivitis

PURPOSE

To study tear film parameters and Meibomian glands in pediatric patients with vernal keratoconjunctivitis (VKC).

METHODS

Forty-four eyes of 22 patients with VKC and 44 eyes of 22 age-matched controls were studied in a hospital-based cross-sectional study. Each subject underwent a complete ophthalmological examination including slit-lamp biomicroscopy, non-invasive break-up time (NIBUT), fluorescein break-up time (FBUT), corneal fluorescein staining, and Schirmer's test. Non-contact meibography was performed using a Sirius topographer.

RESULTS

All patients had VKC grades between 1 and 3 (Bonini scale). The mean NIBUT for cases was 8.83 ± 4.02 s and in controls, it was 15 ± 2.8 s ( P value < 0.001). The mean FBUT for cases was 9.41 ± 3.45 s and in controls, it was 16.7 ± 2.5 s ( P value < 0.001). Schirmer's values were 32 ± 3.1 mm in cases and 21.4 ± 4.1 mm in controls, which were significantly higher ( P value < 0.001). Also, 22.72% of the cases had corneal fluorescein staining in the form of superficial punctuate keratitis, whereas none of the control groups showed corneal staining. The examination of Meibomian glands using non-contact meibography showed a mean Meibomian gland dropout in the upper lid to be 29.7 ± 14.4% in VKC cases and 10.5 ± 3.2% in controls ( P value < 0.001). Meibography of the lower lid showed 25.9 ± 10.2% dropout in cases and 20.5 ± 6.1% in controls ( P value = 0.004).

CONCLUSION

Tear film parameters were significantly deranged in children with VKC in the active stage as compared to age-matched controls. Children with VKC also had a higher Meibomian gland dropout.

Allergen Testing: A Review of the Indications, Procedures, and Limitations in Ocular Allergy

Allergen-based diagnostics are essential in the management algorithm of allergic diseases. Unlike systemic allergy, where the indications and interpretation of these diagnostic modalities are well established, their utility in ocular allergy is not well-defined. With the rising prevalence of ocular allergies and the need for personalized treatment strategies, there is a growing demand for precision allergen diagnostics. This review describes the commonly used tests with their indications, procedures, and limitations. A review of the literature was carried out on articles on allergen diagnostics in ocular allergy, and after excluding articles that were not relevant, 82 papers were included in the current review. IgE-mediated pathways contribute significantly to seasonal and perennial ocular allergy and partly to vernal keratoconjunctivitis. Most diagnostic techniques aim to detect IgE sensitization. In vivo tests include skin prick (SPT), intradermal, and patch tests. SPT is considered the gold standard and directly evaluates the presence of allergen-specific IgE in the skin. In vitro tests measure total and specific IgE from either tears or sera. Tear IgE measurement is relatively specific for allergic conjunctivitis and can provide insight into the potential allergens responsible for local sensitization. The conjunctival provocation test can help establish true allergy, especially in patients with polysensitization. This review also provides an overview of evidence in literature segregated based on the test employed. This includes 17 studies on only SPT; 42 studies on IgE measured in serum, tears, or both; and 20 studies which have evaluated both SPT and IgE. The pattern of allergen sensitization can guide recommendations for avoidance measures and immunotherapy. Thus, this could create a corticosteroid-sparing therapy avenue in these patients, reducing disease severity and resulting visual morbidity.

Combined Papillectomy and Autologous Conjunctival Membrane Graft as Management of Giant Papillae for Severe, Refractory Palpebral Vernal Keratoconjunctivitis-A Case Report

Introduction: Vernal keratoconjunctivitis (VKC) is an allergic disease that predominantly affects young individuals, with a higher incidence among males. Traditionally seen as a condition of childhood that resolves at puberty, recent studies have shown persistent cases in some individuals, potentially influenced by hot and dry tropical environmental conditions. VKC is more prevalent in regions with a hot and humid climate and a high presence of airborne allergens, leading to significant morbidity and impacting the quality of life for affected individuals. Severe and chronic cases can lead to vision-threatening corneal complications, making effective management crucial. Although the clinical profile of VKC varies geographically, comprehensive studies in specific regions remain limited. Case Presentation: In this case report, we present an 18-year-old male patient with severe and refractory VKC. Despite initial treatments, including topical and oral medications, recurrent episodes occurred every 6 months, accompanied by giant papillae (GP) formation and corneal ulcers. The patient had a history of triamcinolone injection and papillectomy combined with amnion membrane transplantation, but presented with a refractory disease in a year. Surgical intervention involving papillectomy and autologous conjunctival membrane graft was performed, leading to a smooth upper tarsal conjunctiva during the 2-year follow-up period, without GP recurrence and maintaining a clear cornea. The patient's symptoms were effectively managed with topical medications. Conclusion: The management of VKC necessitates a comprehensive approach involving preventive measures, pharmacological treatment, and surgical interventions for refractory cases. This case highlights the potential benefits of surgical techniques, such as papillectomy and autologous conjunctival membrane graft, in managing severe and refractory VKC cases with a history of previous surgical procedure failure. However, it is essential to recognize that exposure avoidance and allergic control remain fundamental in VKC management. Further research and larger studies are required to validate the efficacy of these surgical techniques in managing VKC.

Eosinophilic mucus diseases

Eosinophilic inflammation is primarily characterized by type 2 immune responses against parasitic organisms. In the contemporary human being especially in developed countries, eosinophilic inflammation is strongly associated with allergic/sterile inflammation, and constitutes an undesired immune reaction. This situation is in stark contrast to neutrophilic inflammation, which is indispensable for the host defense against bacterial infections. Among eosinophilic inflammatory disorders, massive accumulation of eosinophils within mucus is observed in certain cases, and is often linked to the distinctive clinical finding of mucus with high viscosity. Eosinophilic mucus is found in a variety of diseases, including chronic allergic keratoconjunctivitis, chronic rhinosinusitis encompassing allergic fungal sinusitis, eosinophilic otitis media, eosinophilic sialodochitis, allergic bronchopulmonary aspergillosis/mycosis, eosinophilic plastic bronchitis, and eosinophilic asthma. In these pathological conditions, chronic inflammation and tissue remodeling coupled with irreversible organ damage due to persistent adhesion of toxic substances and luminal obstruction may impose a significant burden on the body. Eosinophils aggregate in the hyperconcentrated mucus together with cell-derived crystals, macromolecules, and polymers, thereby affecting the biophysical properties of the mucus. This review focuses on the clinically significant challenges of mucus and discusses the consequences of activated eosinophils on the mucosal surface that impact mucus and persistent inflammation.

Tear Tacrolimus Levels and Clinical Response After Adjunct Therapy With Cutaneous Application of Tacrolimus 0.1% Over Upper Eyelid Skin in Chronic Vernal Keratoconjunctivitis

PURPOSE

The aim of this study was to evaluate the role of cutaneous application of 0.1% tacrolimus eye ointment over the skin of the upper eyelid in chronic vernal keratoconjunctivitis (VKC).

METHODS

A prospective, longitudinal, noncomparative, open-label clinical study of moderate-to-severe grade steroid-dependent VKC was performed. Study participants were initiated on adjunct therapy of cutaneous application of 0.1% tacrolimus ointment twice daily on the upper eyelid skin. Ocular surface evaluation parameters, meibomian gland imaging, intraocular pressure, visual acuity, and clinical disease severity scoring were performed to assess clinical response at baseline and month 3 of therapy. Tear levels of tacrolimus were measured at month 3 using high-performance liquid chromatography tandem mass spectrometry and correlated with the clinical score.

RESULTS

Palpebral form of VKC was observed in 85% of the cases, with positive family history in 5%, atopy in 7.5%, and keratoconus in 11.25%. Clinical assessment revealed improvement in 97.5% patients with discontinuation of concomitant topical steroids in 64% of patients. There were no changes in visual acuity, intraocular pressure, or ocular surface evaluation after therapy. Tacrolimus was detected in the tears of all our study patients after cutaneous application over the upper eyelid skin, proving its bioavailability with mean tear tacrolimus levels of 6.55 ± 21.43 ng/mL. Correlation analysis revealed a moderate negative correlation between the clinical score and tacrolimus concentration (Spearman correlation coefficient: -0.34, P = 0.002).

CONCLUSIONS

Cutaneous tacrolimus 0.1% ointment over the upper eyelid skin is an efficacious alternative method of application in treatment of VKC, with no resultant ocular irritation.

Visual outcome and postoperative complications of cataract surgery in patients with ocular surface disorders

PURPOSE

To determine the visual outcome and postoperative complications of cataract surgery in patients with ocular surface disorders (OSDs).

SETTING

Tertiary eyecare center in North India.

DESIGN

Retrospective observational study.

METHODS

Patients with various OSDs with stabilized ocular surfaces who underwent cataract surgery during this period and had a minimum postoperative follow-up of 6 weeks were included. The primary outcome measures were postoperative corrected distance visual acuity (CDVA) at 6 weeks, best CDVA achieved, and postoperative complications.

RESULTS

The study included 20 men and 24 women. A total of 55 eyes were evaluated: Stevens-Johnson syndrome (SJS) 35 eyes, ocular cicatricial pemphigoid (OCP) 4 eyes, 8 eyes with dry eye disease (DED), 6 eyes with chemical injury and 2 eyes with vernal keratoconjunctivitis (VKC). The mean duration of OSD was 33.9 ± 52.17 months. The median preoperative CDVA was 2.0 (interquartile range [IQR], 1.45 to 2.0). The median CDVA ever achieved was 0.50 (IQR, 0.18 to 1.45) at 2 months and the median CDVA at 6 weeks was 0.6 (IQR, 0.3 to 1.5). Maximum improvement in CDVA was noted in patients with DED and SJS and the least in OCP. Phacoemulsification was performed in 47.27% eyes with intraoperative complications noted in 9% eyes. Postoperative surface complications occurred in 12 (21.82%) eyes. Other postoperative complications occurred in 9 (16%) eyes.

CONCLUSIONS

Cataract surgery outcome can be visually rewarding in patients with OSDs provided ocular surface integrity is adequately maintained preoperatively and postoperatively.

A Patient-Centered Approach to Vernal Keratoconjunctivitis (VKC): A Podcast

Vernal keratoconjunctivitis (VKC) is a rare yet severe form of allergic conjunctivitis predominantly affecting children, mainly boys, with a global prevalence and a higher incidence in certain geographical regions. The disease is characterized by seasonal exacerbations. VKC presents with ocular surface inflammation leading to various distressing symptoms such as itching, redness, mucous discharge, and pain. The disease primarily manifests bilaterally, though it may initially appear unilaterally. If left untreated, VKC can result in corneal complications, including shield ulcers and vision impairment, affecting daily activities and psychosocial well-being, especially in children. The diagnosis of VKC involves identifying key clinical findings on the ocular surface such as Tranta dots, giant papillae, or shield ulcers. Management follows a stepwise approach, including anti-allergic eye drops, steroid eye drops, and topical medications like cyclosporine, which may take up to 3 months to show efficacy. Allergic sensitization, often to inhaled allergens like pollen and house dust mites, is associated with VKC in half of the cases. Understanding and managing these allergies through measures such as avoidance, sensitization control, and co-treatment of associated conditions like asthma and rhinoconjunctivitis are essential in VKC management. Atopic keratoconjunctivitis (AKC), a related condition associated with atopic dermatitis and asthma, shares similarities with VKC but typically affects young adults. However, there is an observed spectrum between the two diseases, indicating similar treatment strategies for both. VKC treatment requires a patient-centered approach, involving informed and supported parents, considering economic factors due to costly eye drops, and ensuring accessibility and practicality of treatment, especially in children. A multidisciplinary team collaboration, including ophthalmologists, pediatricians, and dermatologists, optimizes patient care. The rewarding aspect of VKC treatment lies in witnessing children regain their quality of life, overcome vision challenges, and thrive in their daily activities. In conclusion, understanding VKC, its associated allergies, and employing a comprehensive, patient-centered approach are crucial in managing this challenging condition, particularly in children, to enhance their vision and overall well-being.

Prevalence and risk factors of Vernal Keratoconjunctivitis among a Ghanaian clinical cohort: A case-control study

Background

Vernal Keratoconjunctivitis (VKC) has been determined to be highly prevalent in countries within the tropical climate region. However, little evidence from studies conducted within this region has been put forward to support this claim.

Aim

To determine the prevalence and risk factors of VKC among a Ghanaian clinical cohort.

Methods

A 3-year case-control study was conducted in a tertiary eye care institution, and medical records of patients who had been diagnosed of VKC between 2018 and 2021 were reviewed.

Results

Medical records of 3800 patients were reviewed. Some 359 cases of VKC were identified, with a population prevalence rate of 9.45 % . Males comprised 57.1 % of the population with VKC, with a male-to-female ratio of 1.33 : 1 . The disease was more prevalent (40.8%) in children (≤ 17 years), and the overall odds of incidence decreased by 10% for a unit increase in age. Age and sex-adjusted models revealed significant positive associations between Keratoconus [aOR = 40.760, 95% CI -5.948 to 339.937], Rhinitis [cOR = 5.183, 95% CI -2.074 to 12.022] and VKC. However, the incidence of VKC was relatively less expressive among pterygium cases [cOR = 0.315, 95% CI -0.077 to 0.846].

Conclusion

VKC is highly prevalent among children and is often associated with comorbidities of atopic origin that exacerbate the impact of the disease among this vulnerable population. It is imperative that clinicians provide holistic care for children with VKC.

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.

Role of the ocular surface microbiome in allergic eye diseases

PURPOSE OF REVIEW

The purpose of this review is to provide an update on emerging literature on the role of the ocular surface microbiome (OSM) in allergic eye diseases.

RECENT FINDINGS

Findings in the literature suggest that the ocular surface microbiome plays a role in the pathophysiology and course of allergic disease of the ocular surface.

SUMMARY

Knowledge regarding the role of the ocular surface microbiome in allergic disease is important to guide development of targets for future therapeutic interventions.

Prevalence and clinical characteristics of vernal keratoconjunctivitis in sub-Saharan Africa

PURPOSE OF REVIEW

Vernal keratoconjunctivitis (VKC) is a chronic bilateral allergic inflammatory disease of the conjunctiva and cornea that affects children and young adults, especially in sub-Saharan Africa. A limbal form (tropical endemic limbo conjunctivitis) is thought to be more common in the tropics where research on this vision-impairing condition is scanty. We sought to review current literature from sub-Saharan Africa, with a focus on the prevalence of VKC and its clinical presentation.

RECENT FINDINGS

There is a variable prevalence of VKC in SSA, up to 32.9% of children, especially in male individuals less than 5 years old, and has been diagnosed in a 4-month-old baby. Associated factors include exposure to dust, personal and family history of atopy, Vitamin D3 deficiency and HIV. The mixed form of VKC is the most frequent form seen and conjunctival pigmentation might be an early diagnostic sign.

SUMMARY

Childhood screening programs for VKC should be established to reduce the morbidity, decreased quality of life and school absenteeism that is seen in these patients. VKC-related research should be encouraged in this milieu to bring to light the particularities of VKC in SSA.

Vernal Keratoconjunctivitis: A Systematic Review

Vernal keratoconjunctivitis (VKC) is a chronic, bilateral corneal and conjunctival problem which typically presents in young individuals. VKC is characterized by itching, photophobia, white mucous discharge, lacrimation, foreign body sensation, and pain due to corneal involvement of shield ulcers. Vernal keratoconjunctivitis is categorized within ocular diseases. The diagnosis is clinical, as no sure biomarkers pathognomonic of the disease have yet been identified. The VKC therapy relies on different types of drugs, from antihistamines and topical steroids to cyclosporine or tacrolimus eye drops. In extremely rare cases, there is also the need for surgical treatment for the debridement of ulcers, as well as for advanced glaucoma and cataracts, caused by excessive prolonged use of steroid eye drops. We performed a systematic review of the literature, according to PRISMA guideline recommendations. We searched the PubMed database from January 2016 to June 2023. Search terms were Vernal, Vernal keratoconjunctivitis, and VKC. We initially identified 211 articles. After the screening process, 168 studies were eligible according to our criteria and were included in the review. In this study, we performed a systematic literature review to provide a comprehensive overview of currently available diagnostic methods, management of VKC, and its treatments.

Preserved Ophthalmic Anti-Allergy Medication in Cumulatively Increasing Risk Factors of Corneal Ectasia

The prevalence of allergies is rising every year. For those who suffer from it, ocular inflammation and irritation can be inconvenient and unpleasant. Anti-allergy eyedrops are a readily available treatment for symptoms of ocular allergy (OA) and can help allergy sufferers regain normal function. However, the eye is a delicate organ, and multiuse eyedrops often utilise preservatives to deter microbial growth. Preservatives such as benzalkonium chloride (BAK) have been shown to induce decreased cell viability. Therefore, during a period of high localised inflammation and eye rubbing, it is important that the preservatives used in topical medicines do not contribute to the weakening of the corneal structure. This review explores ocular allergy and the thinning and protrusion of the cornea that is characteristic of the disease keratoconus (KC) and how it relates to a weakened corneal structure. It also describes the use of BAK and its documented effects on the integrity of the cornea. It was found that atopy and eye rubbing are significant risk factors for KC, and BAK can severely decrease the integrity of the corneal structure when compared to other preservatives and preservative-free alternatives.

Surgical Treatment of Corneal Shield Ulcer in Vernal Keratoconjunctivitis: A Systematic Review

BACKGROUND

Vernal keratoconjunctivitis (VKC) severely affects the quality of life of affected patients. The development of a shield ulcer is considered one of the most severe late-stage complications, which when untreated leads to irreversible vision loss. In this systematic review, we outlined the results of surgical treatments of corneal shield ulcers in VKC.

METHODS

We searched 12 literature databases on 3 April 2023 for studies of patients with VKC in which shield ulcers were treated by any surgical treatment. Treatment results were reviewed qualitatively. Assessments of the risk of bias of individual studies were made using the Clinical Appraisal Skills Programme.

RESULTS

Ten studies with 398 patients with VKC were eligible for the qualitative review. Two categories of surgical approaches were described: supratarsal corticosteroid injection and debridement with or without amniotic membrane transplantation. Almost all patients experienced resolution or improvement of their shield ulcers, regardless of treatment modality. Time to healing was faster with surgical debridement. A small proportion experienced recurrence and side effects.

CONCLUSIONS

Surgical treatment for shield ulcers in VKC seems highly effective, but careful post-operative treatment and follow-ups are necessary due to the risk of recurrence and potential side effects.

Drug Delivery for Ocular Allergy: Current Formulation Design Strategies and Future Perspectives

The incidences of ocular allergy have been growing with the increase in pollution. Because of challenges in new drug development, there have been efforts to maximize the efficacy of existing drugs through drug delivery approaches. The effectiveness of drugs in ophthalmic conditions is primarily determined by permeability across the barrier, corneal retention, and sustained release. Thus, there have been widespread efforts to optimize these parameters to enhance efficacy through novel formulations. This review aims to analyze the approaches to drug delivery systems to encourage further research to optimize effectiveness. With this objective, research on drug delivery aspects of anti-allergy therapeutics was included and analyzed based on formulation/drug delivery technique, Food and Drug Administration approval limits, residence time, compatibility, pre-clinical efficacy, and potential for translational application. Conventional eye drops have concerns such as poor residence time and ocular bioavailability. The novel formulations have the potential to improve residence and bioavailability. However, the use of preservatives and the lack of regulatory approval for polymers limit the translational application. The review may assist readers in identifying novel drug delivery strategies and their limitations for the development of effective ophthalmic formulations for the treatment of ocular allergy.

Efficacy and Safety of 0.1% Cyclosporine versus 2% Cyclosporine in the Treatment of Severe Vernal Keratoconjunctivitis in Children

INTRODUCTION

Vernal keratoconjunctivitis (VKC) is an inflammatory condition in children that can cause severe eye complications. Treatment is based on corticosteroid therapy during flare-ups, then antihistamines and cyclosporine in calmer periods. The dosage and posology of cyclosporine are subject to debate.

METHODS

The aim of the study is to compare the evolution in symptomatic and clinical scores, and need for topical corticosteroid treatment in a population of children with severe VKC treated with two dosages of cyclosporine treatment (0.1% and 2%). Data were compiled on inclusion then every three months from March, with a total follow-up duration of 12 months. Data concerning patient evolutions and complications were collected for the two treatment groups.

RESULTS

The mean age of the 46 children was 8.8 ±2.4 years with age at onset of symptoms of 5.1 ± 0.9 years. The cohort was predominantly (65%) male. Corticosteroid dependence on inclusion was present in 52% of the children included. A significant improvement in the various symptomatic and clinical scores was observed following treatment with cyclosporine (0.1% and 2%). Use of topical corticosteroid treatment reduced from 19 drops per month on inclusion to 4 drops per month at 12 months. Safety was comparable for the two groups.

CONCLUSION

Treatments with cyclosporine 0.1% and 2% lead to a favourable evolution in clinical and symptomatic scores and reduced corticosteroid use. Cyclosporine 0.1% is an interesting alternative to the 2% dosage, particularly due to its availability and ease of handling.

Cyclosporine A Delivery Platform for Veterinary Ophthalmology—A New Concept for Advanced Ophthalmology

Cyclosporine A (CsA) is a selective and reversible immunosuppressant agent that is widely used as a medication for a wide spectrum of diseases in humans such as graft versus host disease, non-infectious uveitis, rheumatoid arthritis, psoriasis, and atopic dermatitis. Furthermore, the CsA is used to treat keratoconjunctivitis sicca, chronic superficial keratitis, immune-mediated keratitis and equine recurrent uveitis in animals. The selective activity of Cyclosporine A (CsA) was demonstrated to be an immunomodulation characteristic of T-lymphocyte proliferation and inhibits cytokine gene expression. Moreover, the lipophilic characteristics with poor bioavailability and low solubility in water, besides the side effects, force the need to develop new formulations and devices that will provide adequate penetration into the anterior and posterior segments of the eye. This review aims to summarize the effectiveness and safety of cyclosporine A delivery platforms in veterinary ophthalmology.

Dysbiosis of Ocular Surface Microbiota in Patients With Refractive Allergic Conjunctival Diseases

PURPOSE

We investigated ocular surface microbiota dysbiosis in patients with refractory allergic conjunctival diseases (ACDs; stratified into mild and severe groups) treated with topical tacrolimus.

METHODS

Patients (n = 21) with refractory ACDs (including vernal and atopic keratoconjunctivitis) actively treated with topical tacrolimus and 6 healthy controls were evaluated. Based on clinical scores and expression of specific cytokines on the ocular surface, patients with ACDs were divided into mild and severe groups using cluster analysis. The microbial composition of tear specimens collected from patients with mild and severe ACD and control subjects using the Schirmer test paper was determined through next-generation 16S rRNA sequencing analysis.

RESULTS

Compared with healthy controls, patients with ACDs exhibited significantly decreased ocular surface microbiota α-diversity. Ocular surface microbiota mainly comprised members of the phyla Actinobacteria, Bacteroidetes, Firmicutes, and Proteobacteria in all groups. The relative abundance of ocular surface microbiota in patients with ACDs was increased for phylum Firmicutes and decreased for phylum Proteobacteria (compared with control subjects). The genera Blautia (vs. mild ACD group) and Morganella (vs. control group) exhibited significantly increased abundance only in the severe ACD group.

CONCLUSIONS

The ocular surface microbiota in patients with severe ACD exhibited decreased diversity and exacerbation of dysbiosis compared with that in patients with mild ACD and control subjects. Patients with mild refractory ACD also exhibited decreased diversity of these microbiota. These alterations in microbiota indicated a change in the ocular surface of patients with refractory ACD (be it because of disease pathogenesis or topical immunomodulatory treatment).

Ocular surface characteristics in pediatric vernal keratoconjunctivitis: a clinico-cytological study

PURPOSE

To compare the ocular surface parameters of children with vernal keratoconjunctivitis (VKC) with those of healthy controls and to correlate cytological characteristics with clinical findings and disease severity.

METHODS

Newly diagnosed cases of VKC, not currently being treated, were recruited, along with age-matched controls with no ocular comorbidities. The Ocular Surface Disease Index questionnaire (OSDI) was administered to all children. Slit lamp biomicroscopy for meibomian gland dysfunction and ocular surface analysis was performed, including tear meniscus height, noninvasive tear film break-up time, lipid layer thickness, meibomian gland morphology, and meibomian gland duct distortion on meibography imaging. Conjunctival impression cytology was also performed.

RESULTS

A total of 68 VKC patients and 33 controls were included. Statistically significant difference was seen in the mean OSDI score (30 ± 13.7 vs 16.1 ± 3 [P ≤ 0.01]), lipid layer thickness (24.2 ± 7.9 nm vs 69.9 ± 15.1 nm [P <0.001]), and noninvasive tear film break-up time (6.8 ± 1.7 vs 12.5 ± 1.8 sec [P < 0.01]) between groups. Mean tear meniscus height was 0.22 ± 0.06 mm in the VKC and 0.24 ± 0.04 mm in the control group (P = 0.096). Significant association was seen between grade of squamous metaplasia and severity of VKC (P < 0.01). Severity of VKC was found to be positively correlated with OSDI score (r = 0.767), grade of squamous metaplasia (r = 0.64) and negatively correlated with noninvasive tear film break-up time (r = -0.468), and lipid layer thickness (r = -0.253).

CONCLUSIONS

This study highlights the poor ocular surface health of children with VKC, with severe disease being associated with worse forms of dry eye disease.

Emerging therapies targeting eosinophil-mediated inflammation in chronic allergic conjunctivitis

Ocular allergy remains a significant burden to the population while the treatment for the severe, chronic forms of allergic conjunctivitis remains largely limited to non-specific immunosuppressants. Eosinophils are central to the pathophysiology and sustaining the immunologic response found in the chronic forms of ocular allergy such as vernal keratoconjunctivitis and atopic keratoconjunctivitis. Several mediators of eosinophil recruitment, chemotaxis, adhesion, activation, and survival have been identified that offer potential therapeutic targets for ocular allergy. Based on preclinical and clinical data available in both ocular and non-ocular allergy studies, these emerging therapies warrant further investigation in reducing the severity of disease in patients with chronic ocular allergy.

Combination Therapy of 0.1% Fluorometholone and 0.05% Azelastine in Eyes with Severe Allergic Conjunctival Diseases: A Randomized Controlled Trial

This study sought to evaluate the efficacy of the isolated use of fluorometholone compared with the combined use of azelastine and fluorometholone for the treatment of severe allergic conjunctival disease (ACD). One hundred and eleven patients with severe ACD were randomized into two groups: one treated with topical 0.1% fluorometholone combined with 0.05% azelastine and the other with 0.1% fluorometholone alone. The Ocular Surface Disease Index (OSDI) and the signs of keratopathy, palpebral conjunctiva papillae and conjunctival congestion were scored before and at one, two and six weeks after treatment and compared between the groups. The intra-ocular pressure (IOP) was also monitored. There were no significant differences between the groups in the baseline mean scores of signs and OSDI scores, which gradually improved at all visits after therapy in both groups. Although the time effect was significant for all the parameters (all p < 0.001), the reduction in corneal involvement scores from week 2 to week 6 was insignificant in both groups (p = 0.460 for the steroids group and p = 0.074 for the combination group). All signs and symptoms were significantly more improved in the combination group than in the isolated group at each control visit. IOP remained stable at all visits (all p < 0.001), except one patient in each group had elevated IOP over 21 mmHg. While both the isolated use of fluorometholone and combined use of azelastine and fluorometholone are effective in alleviating the signs and symptoms of severe ACD, optimal response can be achieved with adjunctive treatment including azelastine.

Effectiveness of a modified therapeutic protocol for the management of vernal keratoconjunctivitis based on Bonini's graded clinical severity

Purpose:

To evaluate the effectiveness of a modified therapeutic protocol used for vernal keratoconjunctivitis (VKC) based on severity as per Bonini grading system.

Methods:

This was a prospective observational clinical study conducted with 123 eyes of 63 patients. A meticulous clinical examination was performed, and data was documented in all the cases. Patients on known systemic atopy and antiallergic therapy were excluded from the study. Eyes with a clinical diagnosis of VKC were segregated based on Bonnini’s grading system. A treatment protocol was created depending on the grade of VKC. Therapeutic responses were documented at 3 weeks, 3 months, 6 months, 12 months, and 24 months. Grading of the eyes was performed in each visit.

Results:

The mean age of the patients was 8.85 years with a standard deviation of 4.48 years. Males were predominant, and 95.24% had bilateral manifestation. The palpebral component was the most common form of manifestation. Itching was the most common manifestation, followed by congestion, discharge, and papillae in a decreasing order. Also, 68% of patients were in grade 2, 14% in grade 3, 12% in grade 1, and the rest were in grade 4. Following the treatment protocol, 70% showed signs of significant improvement in grade by the end of 6 weeks, reaching 90% at the end of 6 months (P = 0.074) and 92% at the end of 12 months (P = 0.002). Also, 52.4% versus 77.8% of patients had no recurrence in the pre- versus posttreatment protocol and it was statistically significant (P = 0.001).

Conclusion:

Grading of VKC gives a clear evaluation of the severity and progression of the condition. Besides, significant improvement in the grades was observed with fewer incidences of recurrences following execution of the therapeutic protocol. Hence, it is essential to maintain a treatment protocol in our clinical practice to provide grade-based therapy and monitor accurate changes in the clinical condition.

Therapeutic Targets in Allergic Conjunctivitis

Allergic conjunctivitis (AC) is a common condition resulting from exposure to allergens such as pollen, animal dander, or mold. It is typically mediated by allergen-induced crosslinking of immunoglobulin E attached to receptors on primed conjunctival mast cells, which results in mast cell degranulation and histamine release, as well as the release of lipid mediators, cytokines, and chemokines. The clinical result is conjunctival hyperemia, tearing, intense itching, and chemosis. Refractory and chronic cases can result in ocular surface complications that may be vision threatening. Patients who experience even mild forms of this disease report an impact on their quality of life. Current treatment options range from non-pharmacologic therapies to ocular and systemic options. However, to adequately control AC, the use of multiple agents is often required. As such, a precise understanding of the immune mechanisms responsible for this ocular surface inflammation is needed to support ongoing research for potential therapeutic targets such as chemokine receptors, cytokine receptors, non-receptor tyrosine kinases, and integrins. This review utilized several published articles regarding the current therapeutic options to treat AC, as well as the pathological and immune mechanisms relevant to AC. This review will also focus on cellular and molecular targets in AC, with particular emphasis on potential therapeutic agents that can attenuate the pathology and immune mechanisms driven by cells, receptors, and molecules that participate in the immunopathogenesis and immunopathology of AC.

MicroRNA Profiling of the Tears of Children With Vernal Keratoconjunctivitis

Vernal Keratoconjunctivitis (VKC) is a chronic conjunctival inflammatory condition that typically affects children. Extracellular microRNAs (miRNAs) are small noncoding RNA molecules, the expression of which is reported to regulate cellular processes implicated in several eye diseases. The aim of this preliminary study is to identify the miRNA expression profile in the tears of children with VKC vis-à-vis controls, and to statistically evaluate these miRNAs as potential diagnostic biomarkers of VKC. The study involved a VKC group and a control group. Tear specimens were collected using Schirmer’s strips. RNA was isolated using miRNeasy Micro kit and quantification was performed using an Agilent Bioanalyzer RNA 6000 Nano kit and Small RNA kit. miRNA profiling was performed using the Agilent microarray technique. A total of 51 miRNAs (48 upregulated and three downregulated) were differentially expressed in the tears of children with VKC and controls. The three most significantly upregulated miRNAs were hsa-miR-1229-5p, hsa-miR-6821-5p, and hsa-miR-6800-5p, and the three most significantly downregulated miRNAs were hsa-miR-7975, hsa-miR-7977, and hsa-miR-1260a. All the upregulated miRNAs are potential diagnostic biomarkers of VKC pending validation due to their larger discriminatory area under the curve (AUC) values. miRNA target prediction analysis revealed multiple overlapping genes that are known to play a role in conjunctival inflammation. We identified a set of differentially expressed miRNAs in the tears of children with VKC that may play a role in VKC pathogenesis. This study serves as the platform study for future miRNA studies that will provide a deeper understanding of the pathophysiology of VKC.

Comparative efficacy of medical treatments for vernal keratoconjunctivitis in children and young adults: a systematic review with network meta-analyses

PURPOSE

To systematically review the literature on the treatment of vernal keratoconjunctivitis (VKC) in children and young adults and conduct comparative efficacy analysis on clinical signs and symptoms using network meta-analyses.

METHODS

We systematically searched the databases PubMed/MEDLINE, EMBASE, Cochrane Central and Web of Science on 21 October 2019 for randomized controlled trials (RCT). Studies considered had patients with VKC < 20 years of age randomized into either intervention (any medical intervention) or comparator (active treatment, placebo treatment or non-treatment control), where pre-defined outcomes (data from ≥2 weeks and as close as possible to 2 months) of symptoms (itching, tearing, photophobia and foreign body sensation) and signs (hyperaemia, punctate keratitis, Horner-Trantas dots and macropapillae) were reported. Risk of bias within studies was evaluated using the Cochrane risk of bias tool. Comparisons were made using network meta-analyses.

RESULTS

We identified 39 studies with data on 2046 individuals. Twenty-three studies were eligible for quantitative analyses. None were systemic therapy. Temporal trend analysis showed that an initial focus on topical mast cell stabilizers turned to a focus on calcineurin inhibitors and a more diverse variety of pharmacological strategies. Studies varied in population, treatment duration and quality. The quantitative analysis revealed that efficacy of different therapies differed substantially across important clinical signs and symptoms, but there was a general trend of superior efficacy when using topical corticosteroids with stronger efficacy of the more potent corticosteroids.

CONCLUSION

We provide an overview of RCTs comparing the efficacy of treatments for VKC in children and young adults, which we find differs across symptoms and signs. Overall, we saw a general trend of superior efficacy with topical corticosteroids. However, our findings highlight the need for better studies, consensus on core outcomes and potential for individualized therapy.

Treating refractory corneal hydrops in a male patient with vernal keratoconjunctivitis and mental retardation: a case report

Background

Keratoconus is the most common noninflammatory bilateral corneal ectasia. Vernal keratoconjunctivitis (VKC) and eye rubbing may be associated with keratoconus in children and young adults. Timely management of advanced keratoconus is important to improve visual quality. In addition, it is challenging to carry out VKC treatment with an intent to avoid the occurrence of punctate epithelial keratitis, ulceration, or corneal neovascularization on corneal grafts.

Case presentation

We report the case of an 18-year-old male patient with a long-term history of mental retardation due to megalencephaly presenting with acute onset of corneal hydrops with prominent bulging and refractory steroid-induced glaucoma of the right eye. The topography of the right eye was unavailable due to advanced ectasia, and that of the left eye revealed central steepening with inferior-superior dioptric asymmetry. According to the clinical findings, the patient was diagnosed with keratoconus. Because of progressive corneal opacity and neovascularization, the patient underwent penetrating keratoplasty (PK) with combination of interrupted and intrastromal running suturing after receiving a preoperative subconjunctival injection of bevacizumab in his right eye, followed by lower eyelid correction. After surgery, the patient was treated with 0.1% tacrolimus dermatological ointment, 0.1% cyclosporine eye drops, artificial tears, and 0.5% loteprednol for keratoplasty and VKC. Repeated education on avoiding eye rubbing was offered to the patient. Two years after PK treatment, his best-corrected visual acuity of the right eye successfully improved from hand motion at 10 cm preoperatively to 6/20 postoperatively.

Conclusions

Large-diameter PK with intrastromal suturing technique for advanced keratoconus could achieve better visual outcomes and avoid suture-related complications. In addition, tacrolimus dermatological ointment rather than tacrolimus topical eye drops or ointment showed satisfactory efficacy when combined with topical cyclosporine and steroid that no significant VKC reactivation were noted after PK.

Sulforaphane inhibits cytokine-stimulated chemokine and adhesion molecule expressions in human corneal fibroblasts: Involvement of the MAPK, STAT, and NF-κB signaling pathways

Chemokines and adhesion molecules are major inflammatory mediators of chronic and recurrent vernal keratoconjunctivitis (VKC). Sulforaphane (SFN) is a natural plant extract that is known to have anti-inflammatory and antioxidant properties. SFN is demonstrated to be effective against a variety of human diseases. The current investigation examines the effects and the molecular mechanisms of SFN on cytokine-induced human corneal fibroblasts (HCFs) expression of adhesion molecules and chemokines. HCFs were exposed to both interleukin (IL)-4 and tumor necrosis factor (TNF)-α in the absence or presence of SFN treatment. The levels of thymus- and activation-regulated chemokine (TARC) and eotaxin-1 in culture supernatants were evaluated using enzyme-linked immunosorbent assay (ELISA). Reverse transcription-polymerase chain reaction analysis (RT-PCR) enabled quantification of mRNA levels of vascular cell adhesion molecule (VCAM)-1, eotaxin-1, and TARC along with cytokine receptors. An immunoblotting assay was used to evaluate the activities of VCAM-1, nuclear factor-kappa B (NF-κB), mitogen-activated protein kinases (MAPKs), signal transducer and activator of transcription factor (STAT)6 pathways, along with the expression of the cytokine receptors including IL-4 receptor (R)α, IL-13Rα1, TNFRI, as well as TNFRII. SFN inhibited TARC and eotaxin-1 release in HCFs stimulated by TNF-α and IL-4 in a manner dependent on dose and time. SFN suppressed transcriptions of TARC, eotaxin-1, and VCAM-1. Furthermore, the mRNA and protein expression levels of IL-4Rα, TNFRI, and TNFRII were also attenuated by SFN exposure, however, those of IL-13Rα1 remained unaffected. In addition, SFN downregulated the expression of VCAM-1 and the phosphorylation of MAPKs, IκBα, and STAT6. These results suggest that SFN inhibited cytokine-stimulated TARC, eotaxin-1 secretion as well as VCAM-1 expression in HCFs, with these effects likely occurring as a result of cytokine receptor inhibition and attenuation of MAPK, NF-κB, and STAT6 signaling. SFN may therefore have therapeutic potential in VKC treatment.

Evaluation of Clinical Efficacy and Safety of Prolonged Treatment of Vernal and Atopic Keratoconjunctivitis Using Topical Tacrolimus

PURPOSE

To evaluate the clinical improvement and safety of prolonged treatment of vernal (VKC) and atopic keratoconjunctivitis (AKC) using topical tacrolimus.

METHODS

We included 36 eyes of 36 patients who had VKC and AKC and were treated with topical tacrolimus ophthalmic suspension (0.1%) for 24 months. The demographic data of the enrolled patients were collected from their medical files. Clinical scores, remission rates, number of relapses, concomitant use of steroids, and refractory indices were assessed. Clinical outcomes were determined using papillae-limbus-cornea (PLC) scores and 5-5-5 exacerbation grading scale scores. Clinical characteristics associated with the need for concomitant steroid eye drops administration were determined using logistic regression analysis. All patients were classified into 3 subgroups using cluster analysis.

RESULTS

PLC scores recorded in the sixth month were significantly improved compared with those recorded at baseline. PLC scores recorded in the 18th, 21st, and 24th months were significantly improved compared with those recorded in the sixth month. The remission rates increased diachronically and significantly, reaching 92% in the 24th month. Logistic regression analysis showed that, for every 10-year increase in patient age, the risk for requiring concomitant administration of steroid eye drops was reduced by half (odds ratio, 0.53; 95% confidence interval, 0.29-0.96). Using cluster analysis, the patients were divided into 3 clusters: adolescent type, pediatric type, and adult type.

CONCLUSIONS

Two years of treatment with topical tacrolimus ophthalmic suspension is an effective method for inducing and maintaining the stable stages of VKC and AKC.

Clinical, histological and immunohistochemistry characteristics of cornea in the sequelae stage of chronic vernal keratoconjunctivitis

Purpose:

To report the clinical outcomes and histopathological and immunohistochemistry (IHC) features in eyes with the sequelae stage of vernal keratoconjunctivitis (VKC).

Methods:

Investigative study of corneal samples obtained following surgical intervention for vision restoration in four eyes of three patients with VKC. Patient 1 (an 11-year-old boy) had deep anterior lamellar keratoplasty in both eyes, Patient 2 (a 24-year-old male) underwent superficial keratectomy followed by penetrating keratoplasty, and Patient 3 (a 22-year-old male) underwent penetrating keratoplasty. The corneal samples retrieved after surgical intervention were assessed for histology features and immunohistochemistry (IHC) studies.

Results:

The grafts were clear till the follow-up of 2–18 months. Histopathology of all four corneal samples showed epithelial hyperplasia, absent Bowman layer, thick hyalinized stromal lamellae, vascularization, and chronic inflammatory cells such as lymphocytes and plasma cells. IHC showed strong expression of CK 3 in both eyes of Patient 1 and no expression in Patients 2 and 3. The marker for limbal stem cells, ABCG2, was absent in all four samples; however, p63α was expressed strongly in Patients 2 and 3, moderately in the right eye of Patient 1, and marginally expressed in the left eye of Patient 1.

Conclusion:

The eyes in the sequelae stage of VKC (having corneal scarring and 360° hypertrophied limbus) can be managed favorably with keratoplasty and amniotic membrane transplantation without allogenic/cadaveric stem cell transplantation. The expression of transient progenitor cells in the scarred corneas of VKC patients in the sequelae stage suggests that the limbal stem cell dysfunction is more likely partial and self-renewal of limbal stem cells is a plausibility in these eyes.

Vernal keratoconjunctivitis and keratoconus

PURPOSE OF REVIEW

Vernal keratoconjunctivitis (VKC) is a severe allergic inflammatory disease affecting the conjunctiva in children and young adults. Keratoconus (KC) is a progressive corneal disease characterized by thinning of the corneal stroma, increased and asymmetric corneal curvature, with a potential for significant visual deterioration and is one of the most common corneal complications of VKC. We aimed to review the association of these two diseases, with focus on the mechanisms, prevalence, natural history and treatment strategies of KC associated with VKC.

RECENT FINDINGS

KC is a common complication of VKC. KC prevalence can be as high as 26.8% among VKC patients, whereas abnormal corneal topography may appear in up to 71% of them. It is more severe and progresses faster in the setting of VKC (P < 0.05), with remarkable visual deterioration and with an increased need for keratoplasty. Crosslinking treatment and corneal transplantation appear to be as effective for KC patients with VKC as compared to the patients without VKC. However, postoperative complications are higher in patients with VKC and demand close monitoring, tight control of local inflammation and prompt awareness with consequent restrain of eye rubbing.

SUMMARY

Patients with VKC should be closely monitored for KC. Prompt recognition of VKC and KC allows tight control of KC pathogenesis mechanisms, timely management of KC progression and preservation of vision and quality of life of young patients.

Combination of 0.05% Azelastine and 0.1% Tacrolimus Eye Drops in Children With Vernal Keratoconjunctivitis: A Prospective Study

Aims: To compare the efficacy of the combination of 0. 05% azelastine and 0.1% tacrolimus eye drops with 0.1% tacrolimus monotherapy in pediatric patients with vernal keratoconjunctivitis (VKC). Methods: Prospective study. Seventy-six patients with VKC were randomized 1:1 into monotherapy group with 0.1% tacrolimus or combination therapy group with 0.1% tacrolimus and 0.05% azelastine. The Ocular Surface Disease Index (OSDI) scores and the signs of conjunctival hyperemia, corneal involvement, and palpebral conjunctiva papillae were assessed at baseline and at 1, 2, and 6 weeks after treatment. Results: Two groups were comparable in age, sex, duration of VKC, OSDI, and clinical signs of VKC at baseline. Significant improvements in OSDI score and clinical signs were observed in both groups at all follow-up visits (all p < 0.001), compared with baseline. The combination therapy group showed a larger decrease in OSDI score from baseline (10.30 ± 0.9) compared with monotherapy group (7.30 ± 0.7, p =0.0085) at 1 week. Greater improvements in conjunctival hyperemia and conjunctival papillae were identified in the combination therapy group, compared with in the monotherapy group, at all follow-up visits (all p < 0.05). The corneal involvement scores in the combination group is significantly lower than the monotherapy group at 2 weeks after the treatment (p = 0.0488). No severe adverse effect was found in either group during the study. Conclusions: Compared with a monotherapy of 0.1% tacrolimus, the combination of 0.05% azelastine and 0.1% tacrolimus eye drops lead to faster and greater improvements in clinical signs and symptoms of vernal keratoconjunctivitis in pediatric patients.

Vernal Keratoconjunctivitis: Beyond the Classic Treatment

Vernal keratoconjunctivitis is a chronic allergic conjunctivitis with corneal involvement that affects children and adolescents. Its pathogenic mechanisms are not entirely clear, but IgE and other inflammatory mediators are involved. An 8-year-old boy with vernal keratoconjunctivitis not responding to conventional treatment started immunotherapy with good results, decreasing the topical steroid dependence. Conventional vernal keratoconjunctivitis treatment involves topical antihistamines and steroids. These are not always effective and steroids can be associated with severe ocular complications in the long term. The authors suggest searching for possible allergens and starting immunotherapy associated with conventional topical treatment earlier, in addition to measuring the health-related quality of life by applying the Quality of Life in Children with Vernal Keratoconjunctivitis questionnaire and adjusting the treatment according to the impact on patients' quality of life. [J Pediatr Ophthalmol Strabismus. 2021;58(5):e36-e39.].

Corticosteroids in the Management of Infectious Keratitis: A Concise Review

Microbial keratitis is devastating corneal morbidity with a variable spectrum of clinical manifestations depending on the infective etiology. Irrespective of the varied presentation delayed treatment can lead to severe visual impairment resulting from corneal ulceration, possible perforation, and subsequent scarring. Corticosteroids with a potent anti-inflammatory activity reduce host inflammation, thus minimizing resultant scarring while improving ocular symptoms. These potential effects of corticosteroids have been applied widely to treat various corneal diseases ranging from vernal keratoconjunctivitis to dry eye disease. However, antimicrobial therapy remains the mainstay of treatment in microbial keratitis, whereas the use of adjunctive topical corticosteroid therapy remains a matter of debate. Understandably, the use of topical corticosteroids is a double-edged sword with pros and cons in the treatment of microbial keratitis. Herein we review the rationale for and against the use and safety of topical corticosteroids in the treatment of infective keratitis. Important considerations, including type, dose, efficacy, the timing of initiation of corticosteroids, use of concomitant antimicrobial agents, and duration of corticosteroid therapy while prescribing corticosteroids for microbial keratitis, have been discussed. This review intends to provide new insights into the therapeutic utility of steroids as adjunctive treatment of corneal ulcer.

Environmental Risk Factors Associated With the Need for Penetrating Keratoplasty in Patients With Keratoconus

Purpose To identify environmental risk factors associated with the need for penetrating keratoplasty (PKP) (full-thickness corneal transplantation) in patients with keratoconus in a Middle Eastern country. Methods This is a retrospective case-control study. This study included patients with keratoconus who underwent PKPor were waitlisted for PKP. Controls were patients diagnosed with keratoconus who did not reach a stage that necessitates PKP. Groups were matched by age and gender. Chi-square test was used to figure out the association between different risk factors including eye rubbing, vernal keratoconjunctivitis (VKC), smoking, paternal consanguinity, eye dryness, family history, asthma, eczema, and diabetes with the need for PKP. Results A total of 111 patients were included in this study, there were 48 (43.26%) men and 63 (56.75%) women. The case group included 42 subjects and the control group included 69 subjects. We found statistically significant differences between the two groups in relation to eye rubbing (p=0.0005), VKC (p=0.005), paternal consanguinity (p=0.02), and smoking rate (p=0.04), all being significant in the group in need of PKP. On the other hand, we did not find out a statistically significant difference between the two groups in relation to family history (p=0.31), dryness (p=0.58), asthma (p=0.15), eczema (p=0.28), or diabetes (p=0.29). Conclusion This study has identified several risk factors associated with the need for PKP in patients with keratoconus, part of which are modifiable. These findings can benefit clinicians in community counseling and give recommendations that can help in preventing or - at least - delaying the need for PKP surgery in keratoconus, such as smoking cessation, aggressive treatment of VKC disease, eye rubbing avoidance, as well as raising awareness regarding the potential risks of paternal consanguinity in this disease entity.

Immunopharmacology in Vernal Keratoconjunctivitis: Current and Future Perspectives

Vernal keratoconjunctivitis (VKC) is a complex and chronic, multifactorial Th2 cell-mediated chronic ocular surface inflammatory condition that typically affects predominantly male children in hot or warm climates. The primary symptom is intense ocular pruritus, often significant enough to affect activities of daily living. Clinical features differ from simple forms of allergic conjunctivitis in that they are more-or-less confined to the superior tarsus and limbus. There is also a risk of corneal involvement, which leads to irreversible vision loss in approximately 6% of patients. Right now, there is no standardized treatment protocol, and many of the currently available options are not effective in severe and recurrent cases. As such, it is imperative to understand this complex allergic immune response in order to identify future therapeutic targets. This review will focus on potential drug targets in VKC, with particular emphasis on immunomodulators and immunobiologic agents.

Preferred practice patterns for photorefractive keratectomy surgery

Over the past two decades, excimer laser-based refractive surgery procedures have been successfully established for their safety and satisfactory visual outcomes. Surface ablation procedures or photorefractive keratectomy (PRK) are practised commonly for the correction of refractive errors including myopia, astigmatism and hyperopia. Satisfactory visual outcomes are achieved in majority of cases, although a very small percentage have issues related to corneal haze, regression, and its associated visual disturbances. To ensure optimal outcomes and to minimize complications, certain keys to success have been designed on the basis of the current review of literature on surface ablation procedures.

Pediatric Keratoconus in A Tertiary Eye Center in Alexandria: A Cross-sectional Study

PURPOSE: To describe the clinical presentation, risk factors, and treatment choices documented in a pediatric keratoconus population treated at a tertiary referral center in Alexandria, Egypt.METHODS: A cross-sectional study of 80 patients with keratoconus aged 18 years or younger referred to the cornea clinic at the Alexandria University Main Hospital between July 2018 and October 2019 was included. Patients' history, initial presentation, best spectacle corrected visual acuity (BSCVA), clinical signs, topographic data, and treatment were recorded.RESULTS: Thirty patients were younger than 14 years and 50 were 14 years or older. Elements of the initial presentation included decreased vision in 26 patients, itching in 20 patients, both visual impairment and itching in 16 patients, accidental discovery during vision screening at school in 15 patients, and hydrops in three patients. All patients had bilateral keratoconus, except for four patients who had previously been treated by keratoplasty (n = 156 eyes). The mean logMAR BSCVA was 0.79 ± 0.63. The mean of the average keratometry (AveK), maximum keratometry (Kmax), central corneal thickness (CCT) and thinnest pachymetry reading were 51.16 ± 7.31 D, 59.18 ± 10.38 D, 458.44 ± 55.87 µ 440.08 ± 60.18 µ, respectively. 57 eyes (36%) had stage 1 disease, 43 eyes (28%) had stage 2 disease, 17 eyes (11%) had stage 3 disease and 39 eyes (25%) had stage 4 disease, respectively. No statistically significant differences in the LogMAR BSCVA, keratometry values, CCT, thinnest pachymetry reading, and the Amsler-Krumeich (AK) staging existed between the two age groups or between boys and girls. Crosslinking was indicated in 69 eyes (44%), while keratoplasty was the only viable solution for 39 eyes (25%), with three patients requiring keratoplasty in both eyes.CONCLUSION: Keratoconus in children can result in severe loss of vision. Keratoconus screening programs in elementary schools should be considered in populations with a high incidence of keratoconus for early detection and adequate intervention.

Evaluation of Olfactory Function in Children With Vernal Keratoconjunctivitis

BACKGROUND

Vernal keratoconjunctivitis (VKC) is a chronic, severe allergic disease of the conjunctiva, which mostly affects young males in early to mid-childhood. There is a high incidence of asthma, allergic rhinitis (AR) and eczema among patients with VKC. It is unknown if VKC patients have abnormal olfactory dysfunction, and if so, whether this is related to AR.

OBJECTIVE

Our aim was to evaluate olfactory function in children with VKC, with and without comorbid AR, in comparison to healthy children without VKC.

MATERIALS AND METHODS

Thirty-nine VKC patients and 32 healthy children were included in the study. After eye and ear, nose and throat (ENT) examination, acoustic rhinometry and modified Connecticut Chemosensory Clinical Research Center (CCCRC) tests were performed and the test results were compared between VKC and control groups and between VKC children with or without AR. A p value <0.05 was regarded as statistically significant.

RESULTS

The VKC group included 25 males (64.1%) with a mean age of 11.13 ± 3.22 years, while the control group included 26 males (81.3%) with a mean age of 12.50 ± 2.13 years (p > 0.05 for both age and gender). Fourteen VKC patients (35.9%) had either positive prick test or elevated serum specific IgE levels against house dust mites and pollens. Mean odor thresholds did not differ between the two groups (p = 0.084), while mean odor identification and CCCRC score were statistically significantly lower in VKC group (6.00 ± 1.02 and 6.81 ± 0.75, respectively) compared to control group (7.06 ± 0.77 and 7.5 ± 0.41, respectively) (p < 0.05, both). Thirteen VKC patients had co-associated AR (33.3%). In VKC patients with AR, mean odor threshold and identification scores were even lower (5.31 ± 0.95 and 6.23 ± 0.78, respectively) (p < 0.05, both).

CONCLUSION

Olfactory function was found to be mildly impaired in children with VKC, especially when co-associated with AR. Therefore, loss of smell should be asked as an extraocular symptom.

Ocular allergy test and biomarkers on the ocular surface: Clinical test for evaluating the ocular surface condition in allergic conjunctival diseases

Allergic conjunctival diseases (ACDs) are inflammatory diseases of the conjunctiva and cornea caused predominantly by the IgE-mediated immediate hypersensitivity response. Allergic conjunctival diseases include allergic conjunctivitis, vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), and giant papillary conjunctivitis. In clinical practice of ACDs, an ocular allergy test using biomarker measurement is a crucial examination technique for diagnosing, evaluating severity, and determining the efficacy of medical treatment. The ocular allergy test includes the tear test for evaluating the concentration of biomarkers in tears and an ocular surface test for assessing the expression levels of messenger ribonucleic acid (mRNA) biomarkers on the ocular surface. The clinical usefulness of several biomarkers has been demonstrated in patients with ACDs; specifically, eosinophil cationic protein and eotaxin-2 as eosinophilic inflammation biomarkers; interleukin-4 and thymus and activation regulated chemokine (CCL17/TARC) as Th2 inflammation biomarkers; eotaxin, tumor necrosis factor-alpha and soluble IL-6 receptor as giant papillae biomarkers; and osteopontin and periostin as allergic inflammation and remodeling biomarkers. Furthermore, the ocular allergy test, quantitative evaluation methods using biomarkers have allowed for better understanding of the immunological and pathophysiological mechanisms of ACDs. Therefore, the search for a biomarker is important to make an ocular allergy test useful. In previous ocular allergy tests, the biomarkers for allergic inflammation in patients with chronic ACDs including VKC and AKC were substantial. However, the selection of biomarkers associated with the early phase reaction of immediate hypersensitivity and innate immunity responses needs to be addressed in future investigations.

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.

Conjunctivitis: A Systematic Review

Conjunctivitis is a commonly encountered condition in ophthalmology clinics throughout the world. In the management of suspected cases of conjunctivitis, alarming signs for more serious intraocular conditions, such as severe pain, decreased vision, and painful pupillary reaction, must be considered. Additionally, a thorough medical and ophthalmic history should be obtained and a thorough physical examination should be done in patients with atypical findings and chronic course. Concurrent physical exam findings with relevant history may reveal the presence of a systemic condition with involvement of the conjunctiva. Viral conjunctivitis remains to be the most common overall cause of conjunctivitis. Bacterial conjunctivitis is encountered less frequently and it is the second most common cause of infectious conjunctivitis. Allergic conjunctivitis is encountered in nearly half of the population and the findings include itching, mucoid discharge, chemosis, and eyelid edema. Long-term usage of eye drops with preservatives in a patient with conjunctival irritation and discharge points to the toxic conjunctivitis as the underlying etiology. Effective management of conjunctivitis includes timely diagnosis, appropriate differentiation of the various etiologies, and appropriate treatment.

Serum Vitamin D Level and Body Mass Index in Children with Vernal Keratoconjunctivitis

OBJECTIVES

The purpose of this study was to evaluate the body mass index (BMI) value and serum 25-hydroxyvitamin D [25(OH)D3] level in children with vernal keratoconjunctivitis (VKC).

METHODS

A total of 40 healthy, non-atopic children (control group) and 46 children with VKC (study group) were included in the study. The serum vitamin D [25(OH)D3] levels and BMI values were measured and compared between the 2 groups.

RESULTS

The mean vitamin D level measured in the healthy children (mean: 19.01±5.66 ng/mL, range: 9-33.09 ng/mL) was significantly different from the mean vitamin D level in the VKC-affected children (mean: 14.06±5.02 ng/mL, range 4.37-31 ng/mL) (p<0.001). The mean BMI in the VKC group (17.1±2.5 kg/m²) was significantly higher than the mean BMI of the healthy children (mean: 16.5±2.3 kg/m²; p=0.046). A negative correlation (Spearman's rho=-0.275; p=0.01) was observed between the vitamin D level and the BMI value.

CONCLUSION

The results indicated that children with VKC had a lower serum vitamin D level and a higher BMI value compared with healthy, age- and sex-matched children.

Surgical debridement of corneal shield ulcers in pediatric patients: two case reports and a review of the literature

Background

Ocular allergy is a common disease, especially in the pediatric population, with unpleasant and long-term consequences, including corneal complications and decreased visual acuity. This study reports two cases of corneal shield ulcer due to vernal keratoconjunctivitis, with good results of surgical debridement performed after failure of long-term clinical treatment. Furthermore, this study highlights that this therapeutic approach, although less common, is efficient in treating refractory cases that cause suffering in pediatric patients.

Case presentation

The first patient was a 7-year-old Caucasian boy with chronic ocular allergy, especially photophobia, who had been treated with eye drops, antihistamine, and corticosteroids for 60 days without success. Biomicroscopy of the right eye showed the presence of gelatinous limbus, giant papillae in the tarsal conjunctiva, and a shield ulcer measuring 6.0 mm vertically and 2.7 mm horizontally. Surgical debridement was performed, and the ulcer did not recur. The second patient was a 4-year-old Caucasian boy with chronic ocular allergy, especially itching and photophobia, who had been treated with eye drops for 1 year without success. Biomicroscopy of the left eye showed a shield ulcer, with a dense central corneal plaque, measuring 8 mm vertically and 3.5 mm horizontally. Surgical debridement of the ulcer was performed immediately because of the chronicity of the case and severity of the lesion, and the treatment was effective.

Conclusions

The treatment of shield ulcers caused by vernal keratoconjunctivitis in the two reported cases was curative and definitive by surgical debridement in the 7-month follow-up period. Therefore, the early debridement of shield ulcers refractory to drug treatment can considerably reduce the time of disease evolution and the probability of ocular complications caused by clinical treatment or disease chronicity. However, this approach is rarely described in the literature and needs to be included in the ophthalmologist’s therapeutic arsenal.