Vernal keratoconjunctivitis

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.

A Case of Vernal Keratoconjunctivitis With Growth Hormone Deficiency

Hormonal abnormalities are considered to play a role in the development of vernal keratoconjunctivitis (VKC). However, little is known whether about growth hormone (GH) is related to VKC development. The patient was an 11-year-old male with VKC treated with 0.1% betamethasone eye drops and 0.1% cyclosporin eye drops. The papillary growth of both superior and inferior palpebral conjunctiva worsened, and masses started to appear at the lower palpebral margin. He was referred to our hospital and was treated with 0.1% tacrolimus and 0.1% fluorometholone. Six weeks later, the condition improved remarkably. At this timepoint, we noticed the patient's short stature and asked again about his past history. Two years ago, he was diagnosed with GH deficiency (GHD), which had been treated with somatropin in a pediatric clinic. Thus, it is necessary to keep in mind the possibility of GHD when treating VKC patients.

Knowledge, Attitude, and Practice Among Caregivers of Children With Vernal Keratoconjunctivitis in a Tertiary Care Pediatric Hospital

PURPOSE

To determine the knowledge and attitude about vernal keratoconjunctivitis (VKC) and factors affecting the practice and compliance with treatment in caregivers of children with VKC.

METHODS

The study was conducted in a tertiary care pediatric hospital in northern India. It was a hospital-based cross-sectional study in which 65 caregivers (parents or guardians) were interviewed regarding their knowledge about the disease and attitude of caregivers.

RESULTS

Of 268 children with VKC visiting the ophthalmology department during the study period, 65 children met the inclusion criteria; 53 (81.54%) were boys and 12 (18.46%) were girls. A total of 69.2% of caregivers were not aware of the symptoms of the disease and 83% of caregivers were unaware of the side effects of eye drops used. A total of 24.61% of caregivers considered VKC affected school hours and other recreational activities of children (P < .001). Compliance with treatment decreases with more episodes of VKC and longer duration of symptoms.

CONCLUSIONS

The chronic course of the disease affects compliance with treatment and follow-up with an eye specialist. Proper education of caregivers of children with VKC can influence the compliance with treatment. [J Pediatr Ophthalmol Strabismus. 2021;58(6):390-395.].

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.

Vernal keratoconjunctivitis: An update

Vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) are potentially severe and complex disease in its management among the various allergic eye diseases. In this regard, studies clarified the etiopathogenetic mechanisms. The workup should be multidisciplinary. The treatment includes topical and systemic medications with anti-inflammatory and immunosuppressant activity. However, a definition of nationally- and internationally-shared diagnostic protocols would also be needed and validated access to therapeutic options of proven safety and efficacy to avoid the use of galenic preparations, up to now still essential in the management of moderate-severe VKC. Finally, recognizing VKC and AKC, among rare diseases, at a national and international level would be an essential step to allow the management of VKC with adequate timings and settings within the National Health System.

Allergy and Dry Eye Disease

Ocular allergy (OA) and dry eye disease (DED) are the most common ocular surface disorders with a potential severe impact on the patient's quality of life. OA and DED may coexist and have a significant clinical overlap. Therefore, clinical features commonly believed to be distinctive of OA or DED may be sometimes insufficient for a differential diagnosis. Alterations of the tear film, epithelial barrier, and corneal innervation are described in OA and can pave the way to DED. Conversely, DED may facilitate or worsen allergic reactions in predisposed (atopic) patients. For these reasons, OA and DED should be considered as reciprocal predisposing conditions that share ocular surface inflammation as a common background.

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.

Observer-masked trial comparing efficacy of topical olopatadine (0.1%), bepotastine (1.5%), and alcaftadine (0.25%) in mild to moderate allergic conjunctivitis

Purpose:

With increasing environmental pollution, the incidence of allergic conjunctivitis is increasing. Newer anti-allergic medications with combined anti-histaminic and mast cell stabilization action can help reducing the use of topical steroids for milder form of disease. There is no study directly comparing olopatadine (0.1%), bepotastine (1.5%), and alcaftadine (0.25%) for mild to moderate allergic conjunctivitis cases. Hence, we decided to methodically study the efficacy of three topical medications.

Methods:

Prospective, observer-masked clinical trial enrolled 45 patients with 15 patients in each of the three groups. Patients with mild to moderate allergic conjunctivitis were sequentially assigned to respective groups, and relief of symptoms and signs were noted upto 1-month follow-up.

Results:

All three topical medications faired almost equally in resolving symptoms of the patients with mild to moderate allergic conjunctivitis, and most of them reported complete relief after 1 week of use of medication. Few cases with limbal or palpebral papillae reported symptomatic relief after use of medication, but the resolution of these signs was not noted in all three groups.

Conclusion:

We concluded similar efficacy of three medications in relieving symptoms and inefficacy in regressing palpebral and limbal papillae in cases of allergic conjunctivitis.

Efficacy, Safety and Steroid-sparing Effect of Topical Cyclosporine A 0.05% for Vernal Keratoconjunctivitis in Indian Children

Purpose

To evaluate the efficacy, safety, and steroid-sparing effect of topical cyclosporine A (Cs A) 0.05% in patients with moderate to severe steroid dependent vernal keratoconjunctivitis (VKC).

Methods

A prospective, comparative, placebo controlled study was carried out on 68 VKC patients, with 34 patients treated with topical Cs A 0.05% and the remaining 34 with topical carboxymethyl cellulose 0.5% (placebo). Both groups also received topical loteprednol etabonate 0.5%. Symptom (itching, photophobia, tearing, and discharge) score, sign (tarsal and limbal papillae, corneal involvement, and conjunctival hyperemia) score, and drug score (steroid drop usage/day/eye) were recorded at baseline and each follow-up visit. The intraocular pressure (IOP) measurement and evaluation of any ocular side effects were carried out.

Results

Significant reduction in symptom score and sign score was seen in both groups. Cs A group significantly showed more reduction in symptom (P < 0.0001 in all follow-up visits) and sign (P < 0.0001 in all follow-up visits) scores compared to the placebo group. At day 7, mean steroid usage reduced from 4 to 3.44 ± 0.5 and 3.79 ± 0.4 in Cs A and placebo groups, respectively (P < 0.0001). Steroid drops completely stopped in 21 patients at day 60 in the Cs A group compared to none in the placebo group. No significant rise in IOP or any side effects were noted in either group.

Conclusion

Topical Cs A 0.05% is effective and safe in patients with moderate to severe VKC with good steroid-sparing effect.

A Novel Approach of Drug Localization through Development of Polymeric Micellar System Containing Azelastine HCl for Ocular Delivery

BACKGROUND

Development of polymeric micelles for the management of allergic conjunctivitis to overcome the limitations of topical installation, such as poor patient compliance, poor stromal permeability, and significant adverse effects, increase precorneal residence time and efficacy, and also control the release of drug at the target site.

OBJECTIVE

The investigation was aimed at developing a polymeric micellar system of Azelastine HCl for Ocular Delivery.

METHODS

Drug loaded micelles of tri-block copolymers Pf 127 were prepared by Thin Film hydration method. The polymeric micelles formulations (F1 to F9) were assessed for entrapment efficiency, micelle size, in vitro permeation, ex vivo transcorneal permeation, in vivo Ocular Irritation, and Histology.

RESULTS

Optimized micelles formulation (F3), with the lowest micelle size of 92 nm, least polydispersity value of 0.135, highest entrapment efficiency of 95.30 ± 0.17%, and a cumulative drug permeation of 84.12 ± 1.26% in 8h, was selected to develop pH-sensitive micelles loaded carbopol in situ gel. The optimized in situ gel (G4) proved to be superior in its ex vivo transcorneal permeation when compared with Market Preparation and pure drug suspension, exhibiting 43.35 ± 1.48% Permeation with zero-order kinetics (r2 = 0.9944) across goat cornea. Transmission Electron microscopy revealed spherical polymeric micelles trapped in the gel matrix. A series of experiments showed hydration capability, non-irritancy, and histologically safe gel formulation that had appropriate handling characteristics.

CONCLUSION

A controlled release pH-sensitive ocular formulation capable of carrying the drug to the anterior section of the eye via topical delivery was successfully developed for the treatment of allergic conjunctivitis.

Clinical implications of mast cell involvement in allergic conjunctivitis

The conjunctiva is a common site for the allergic inflammatory response due to it being highly vascularized, having constant exposure to environmental pollutants and allergenic pollens and having a unique conjunctival associated lymphoid tissue. The primary morbidity of anterior surface conjunctival disorders that include allergic conjunctivitis and tear film disorders is associated with its high frequency of involvement rather than its severity, although the more chronic forms can involve the cornea and lead to sight-threatening conditions. Ocular allergy is associated with IgE-mediated mast cell activation in conjunctival tissue leading to the release of preformed mediators including histamine and proteases and subsequent de novo formation of lipid-derived mediators and cytokines that trigger a cascade of cellular and molecular events leading to extensive migration and infiltration of inflammatory cells to the ocular surface. The trafficking of neutrophils, eosinophils, and lymphocytes to the ocular surface is due to establishing various chemokine gradients (mainly CCL11, CCL24, CCL5, MCP-3, and MCP-4), cell surface expression of adhesion molecules (such as VCAM-1 the ligand for VLA-4), and leukocyte adhesion to vascular endothelium. The release of preformed mediators underlies the acute ocular surface response while the secondary influx of inflammatory cells leading to the recruitment and activation of eosinophils and the subsequent activation of Th2 and Th1 lymphocytes at the level of the conjunctiva reflects the late-phase reaction.

T helper subsets in allergic eye disease

PURPOSE OF REVIEW

Ocular allergy is an IgE-mediated disease that results in inflammation of the conjunctiva and, in more severe cases, the cornea. This is driven by an immediate hypersensitivity response via mast cells, followed by a late phase response mediated by eosinophils both of which are indeed dependent on T helper (Th) lymphocyte activity. Here, we provide an update on Th subsets [Th1, Th2, Th17, and T regulatory (Treg)] and their relevance in ocular allergy.

RECENT FINDINGS

Recent evidence in ocular allergy points to an involvement of other Th subsets, in addition to Th2. However, how these subsets are activated and their role in mediating the different clinical forms is poorly understood. Novel mouse models may facilitate addressing such unknowns, and future challenges will involve how to translate such findings into more effective and 'patho-specific' treatments.

SUMMARY

Ocular allergy, especially in severe forms, involves subsets other than Th2. Th1 cells have been detected in mild and severe forms, and recent evidence points to a possible role for IL-17 in severe disease. Tregs, on the other hand, dampen pathogenic Th cell function and allergy immunotherapy is associated with Treg augmentation in disease management. Further understanding of Th biology is warranted and may lead to better therapies.

Demographic and clinical profile of vernal keratoconjunctivitis at a tertiary eye care center in India

Purpose:

To study the demographic and clinical profile of patients with vernal keratoconjunctivitis (VKC) at a tertiary eye care center in India.

Materials and Methods:

Retrospective chart analysis of 468 patients of VKC seen from January 2006 to December 2006.

Results:

Mean age at presentation was 12 years. Majority of the patients had mixed pattern disease (72%). Chronic perennial disease was seen in 36% patients. Personal or family history of allergies was noted in 5% patients. Severe disease based on clinical grading was present in 37% patients. Moderate to severe vision loss was seen in 12% of total population. Persistent disease beyond 20 years of age was found in 12% patients. VKC-related complications such as corneal scarring (11%), shield ulcer (3%), keratoconus (6%), and limbal stem cell deficiency (1.2%) were seen. Treatment-related complications like corticosteroid-induced cataract and glaucoma were seen in 6% and 4% of patients, respectively.

Conclusion:

Clinical pattern of VKC seen in the tropical climate of India is essentially similar to that seen in other tropical countries. Few distinct features that we noted represent chronic perennial disease, low association with atopy, and higher propensity for disease and treatment-related complications.

Increased incidence of thyroid dysfunction and autoimmunity in patients with vernal keratoconjunctivitis

Hormones may play a role in the pathophysiology of vernal keratoconjunctivitis (VKC). An increased incidence of thyroid autoantibodies was recently observed in VKC, although there were no data on thyroid function. Two hundred and eighty-eight patients (202 males, 86 females; range 5.5 to 16.9 years) with VKC were evaluated and compared with 188 normal age- and sex-matched subjects. In all subjects, serum concentrations of free T4, TSH, thyroperoxidase, thyroglobulin, and TSHr autoantibodies were evaluated. In VKC, the family history of thyroid diseases showed no significant differences compared to the controls (9.4 versus 8.6%), whereas the family history of autoimmune diseases was significantly higher (13.2% versus 6.3%; P<0.05). Subclinical hypothyroidism was diagnosed in 6.6% (versus 1.6% of the controls; P<0.05) and overt hypothyroidism in 0.7% (versus 0.0% of the controls; P = NS). Finally, 5.2% of patients were positive for thyroid autoantibodies, which were significantly higher with respect to the controls (0.5%, P<0.05). In the patients positive for thyroid autoantibodies, 80% showed a sonography pattern that suggested autoimmune thyroiditis. Thyroid function and autoimmunity abnormalities are frequently present in children with VKC. Children with VKC should be screened for thyroid function and evaluated for thyroid autoimmunity.

Allergic conjunctivitis: a comprehensive review of the literature

Ocular allergy represents one of the most common conditions encountered by allergists and ophthalmologists. Allergic conjunctivitis is often underdiagnosed and consequently undertreated. Basic and clinical research has provided a better understanding of the cells, mediators, and immunologic events, which occur in ocular allergy. New pharmacological agents have improved the efficacy and safety of ocular allergy treatment. An understanding of the immunologic mechanisms, clinical features, differential diagnosis, and treatment of ocular allergy may be useful to all specialists who deal with these patients. The purpose of this review is to systematically review literature underlining all the forms classified as ocular allergy: seasonal allergic conjunctivitis, perennial allergic conjunctivitis, vernal keratoconjunctivitis, atopic keratocongiuntivitis, contact allergy, and giant papillary conjunctivitis.

Clinical and Cytologic Evidence of Limbal Stem Cell Deficiency in Eyes With Long-Standing Vernal Keratoconjunctivitis

PURPOSE

We aimed to study the impression cytology (IC) of the ocular surface in eyes with vernal keratoconjunctivitis (VKC) and clinical evidence of limbal stem cell deficiency (LSCD).

DESIGN

This is a prospective comparative study.

METHODS

This study included 78 eyes of 40 patients with VKC. Limbal stem cell deficiency was diagnosed clinically based on the presence of corneal findings such as dull irregular epithelial reflex, superficial neovascularization, conjunctivalization, and loss of limbal palisades of Vogt. The study group consisted of 28 eyes of 15 patients with clinically diagnosed LSCD and control group of 50 eyes of 25 patients without LSCD. Conjunctival and corneal IC was done in all eyes. Presence of goblet cells in the corneal samples on IC was considered confirmatory of LSCD.

RESULTS

Compared with controls, patients with LSCD were older and had longer duration of disease. On IC, goblet cells were present on the cornea in 53.6% of eyes with clinically diagnosed LSCD and in none of the control eyes (P < 0.0001). Clinically diagnosed LSCD in study eyes correlated with cytologic findings of greater conjunctival squamous metaplasia, decreased conjunctival goblet cells, greater corneal cell metaplasia, and increased inflammation as compared with control eyes.

CONCLUSIONS

Most of the eyes with VKC and clinical evidence of LSCD have cytologic evidence of LSCD with goblet cells on the cornea.

Steroid-induced ocular hypertension in Asian children with severe vernal keratoconjunctivitis

Background

We describe clinical characteristics and risk factors for corticosteroid response in children with severe vernal keratoconjunctivitis (VKC).

Design

Retrospective, noncontrolled, comparative case series.

Participants

Patients from three tertiary centers in Singapore.

Methods

We reviewed patients with severe VKC (clinical grade > 2) who were on topical steroid therapy, with a minimum follow-up period of 1 year post-presentation. Logistic regression was used to determine risk factors for corticosteroid response.

Main outcome measure

Corticosteroid response was defined as intraocular pressure (IOP) >21 mmHg (three consecutive readings), or a rise of more than 16 mmHg from baseline, after commencement of steroid therapy in the absence of other possible causes of raised IOP.

Results

Forty-one of 145 (28.3%) patients developed a corticosteroid response, of which eight (5.5%) progressed to glaucoma. The overall mean age of onset of VKC was 9.9 ± 4.4 years. Longer duration of corticosteroid use (OR, 5.06; 95% CI: 1.04–25.56; P = 0.45) and topical dexamethasone 0.01% (OR, 2.25; 95% CI: 1.99–5.08; P = 0.40) were associated with corticosteroid response. Mixed type of VKC (OR, 9.76; 95% CI: 3.55–26.77; P < 0.001), the presence of limbal neovascularization of ≥ three quadrants (OR, 6.33; 95% CI: 2.36–16.97; P < 0.001), and corneal involvement (OR, 3.51; 95% CI: 1.31–9.41; P = 0.012) were significant clinical risk factors after adjusting for potential confounders such as age, sex, ethnicity, duration, and type of corticosteroid used.

Conclusion

Children on long-term oral corticosteroids with severe, mixed-type VKC and corneal involvement are more likely to develop corticosteroid response, and may require early treatment to prevent progression to glaucoma.

Ocular complications of severe vernal keratoconjunctivitis (VKC) in Yemen

OBJECTIVES

The objective of this study was to assess the ocular complications and visual loss among patients with severe vernal keratoconjunctivitis (VKC).

METHODS

Four hundred and thirty-one patients with VKC seen at Ibn Al-Haitham Eye Center were the study group. This is a retrospective non-comparative observational study between 01 January 2002 and 31 December 2002. Visual acuity was measured with the standard Snellen visual acuity chart and for children under 5 years of age Kay pictures were used. Visual impairment was assessed by means of the World Health Organization criteria for visual disabilities. Cases with severe VKC that developed ocular complications leading to blindness and severe visual impairment were analyzed.

RESULTS

The majority of VKC patients were males (75.9%) with a male:female ratio of 3.1:1. A total of 68 (15.7%) patients (54 boys and 14 girls) had severe VKC. The ocular findings among 20 patients with severe VKC that led to blindness and severe visual impairment included keratoconus (7); steroid-induced cataract (5), central corneal scars (5) and steroid-induced glaucoma (3). Two of the keratoconus cases developed acute hydrops.

CONCLUSION

Severe VKC in developing countries including Yemen is a potentially blinding disease. Visual loss may be due to keratoconus and corneal scars, as well as complications of the unsupervised use of topically administered corticosteroids.

Ocular surface disease: a case of vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a recurrent, chronic allergic inflammation of the ocular surface associated with remodeling of the cornea and conjunctiva, with a potential to adversely affect the patient's vision and quality of life. It affects mainly children and young adults. The purpose of this interventional case report is to present a typical case of limbal VKC, which was unresponsive to antiallergic treatment alone. A 5-year-old boy, who was previously unsuccessful with conventional anti-allergic therapy alone, presented with clinicopathological features pathognomonic of limbal VKC. The patient was successfully managed with a combination of palliative, anti-allergic and anti-inflammatory therapy. Prophylaxis with an anti-allergic pharmaceutical agent was initiated for long term use to prevent the release of allergic mediators. This case highlights the importance of prescribing the most appropriate pharmaceutical medication for VKC since conjunctival fibroproliferative lesions are often resistant to anti-allergy therapy. Allergic inflammatory mediators are responsible for the fibroproliferative changes of the conjunctiva and corneal lesions in VKC. Thus, it is crucial to prescribe the most appropriate pharmaceutical medication that will prevent the release of allergic inflammatory mediators, control the allergic inflammatory cascade and prevent ocular surface damage. The fine points of this case are presented with a review of applicable literature.

Tailored approach to the treatment of vernal keratoconjunctivitis

PURPOSE

To develop a standardized clinical grading system for the management of patients with vernal keratoconjunctivitis (VKC) and to identify the risk factors associated with a worsened outcome of the disease, including decrease of visual acuity and ocular complications development.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 207 consecutive patients with VKC, referred to our Cornea and External Diseases Center from 1997 to 2007, were included in the study. A total of 110 of those patients were included in the follow-up study (range 1-10 years).

METHODS

Classification and regression tree (CART) analysis was performed to separate the patients into 5 subgroups by therapeutic approach. Regression tree and multivariate logistic regression analyses were performed during follow-up to identify predictors of worse visual outcome.

MAIN OUTCOME MEASURES

Age, gender, duration and course of disease, signs, symptoms, overall symptoms score, history of atopy, markers of allergy, best-corrected visual acuity, and therapy were collected at baseline and during follow-up. The number of relapses and number of patients with decreased visual acuity were also evaluated in the follow-up.

RESULTS

A decision tree for VKC treatment was developed by CART analysis, and a new clinical grading system was proposed accordingly. Sixteen patients were classified as grade 0 (absence of symptoms and no therapy); 59 patients were classified as grade 1 (presence of symptoms without photophobia, occasional use of anti-allergic eye drop); 74 patients were classified as grade 2 (presence of symptoms including photophobia, daily anti-allergic treatment); 22 patients with superficial punctuate keratopathy (SPK) were classified as grade 3 (daily anti-allergic treatment associated with occasional topical steroid); and 36 patients were classified as grade 4 (diffuse SPK or corneal ulcer; pulsed high-dose topical steroid). A higher number of relapses and a higher baseline grade of VKC were the main predictor factors for worse visual outcome.

CONCLUSIONS

This grading system allows for identifying the more severe forms of VKC that are at higher risk of recurrences, corneal ulceration, and worse final visual outcome.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Pharmacotherapy of allergic eye disease

Allergic eye disease is a term that refers to a number of disease processes that affect about one-fifth of the world's population. Although the more advanced forms of the disease can be sight threatening, the most disabling effects are due to the clinical manifestations, and hence quality of life, with some patients having seasonal exacerbations of their symptoms, whereas others have symptoms that are present throughout the year. Recent increased understanding of the cellular and mediator mechanisms that are involved in the various disease manifestations has greatly facilitated the development of more effective treatment options. Newer topical medications are being used that have multiple actions, such as an antihistaminic effect coupled with mast-cell stabilisation, and which require reduced daily dosing due to their longer duration of action. With greater research into newer therapies and more effective modes of delivery, improved healthcare outcomes with a lower economic burden will be achieved for patients with allergic eye disease.

Systematic review and meta-analysis of randomised clinical trials on topical treatments for vernal keratoconjunctivitis

AIMS

The aim of this study was to assess the efficacy of currently available topical drugs for vernal keratoconjunctivitis (VKC) through a meta-analysis of randomised clinical trials (RCTs).

METHODS

Twenty-seven RCTs (n = 2184 eyes) that had evaluated the efficacy of topical drugs for the treatment of VKC were selected according to the set criteria; 10 of these trials were suitable for statistical analysis and were enrolled in the meta-analysis. Articles published up to December 2005 were identified from the following

DATA SOURCES

Medline, Embase, Lilacs, the Cochrane Controlled Trials Register, and references from relevant articles. Articles in any language published with an English abstract, were screened, and those selected for inclusion were written in English, French, German, Italian, Portuguese or Spanish. The quality of the trials was assessed by the Delphi list. Statistical analysis was performed using STATA software.

RESULTS

A significant improvement in all signs and symptoms, except photophobia, was observed after topical treatment for active VKC, independent of the type of treatment. Comparison of the efficacy of different drugs was not possible due to a lack of standardised criteria among studies.

CONCLUSION

The currently available topical drugs are effective in treating acute phases of VKC. However, there is a lack of evidence to support the recommendation of one specific type of medication for treating this disorder. There is a need for standard criteria to assess diagnosis and therapy based on severity. There is also a need for RCTs assessing long-term effects of single drugs to control the disease and to prevent complications.

Secondary Bacterial Keratitis Associated With Shield Ulcer Caused by Vernal Conjunctivitis

PURPOSE

To report a patient with vernal keratoconjunctivitis-induced shield ulcer superinfected with Staphylococcus aureus.

METHODS

Observational case report. A 12-year-old boy who had been followed for vernal keratoconjunctivitis for 3 years was admitted to our clinic complaining of visual loss, photophobia, and a ropy discharge. On slit-lamp examination, a transversely oval shield ulcer, which was situated in the center of the superior third of the cornea, was seen in the left eye. The vernal corneal plaque area and margins were infiltrated, and hypopyon was also observed. With the diagnosis of shield ulcer with secondary bacterial keratitis and hypopyon, the patient underwent medical treatment consisting of topical fortified cefazolin (50 mg/mL) and tobramycin (14 mg/mL), lodoxamide 0.1%, prednisolone acetate 1%, cyclopentolate, and systemic cetirizine.

RESULTS

After treatment, the bacterial keratitis, shield ulcer, and inflammation in the anterior chamber disappeared.

CONCLUSION

Bacterial keratitis associated with shield ulcer may be rarely observed in patients with vernal keratoconjunctivitis. Prompt diagnosis and treatment may prevent permanent complications and vision loss.

[Ocular allergies]

Recent developments indicate that ocular allergy is more than an IgE-mediated allergic conjunctivitis. Ocular allergy is a disease affecting the entire ocular surface including conjunctiva, lids, cornea, lacrimal gland and tear film. Besides an IgE-mediated reaction, a complex chronic inflammation is involved in the pathogenesis of many ocular allergies. According to their pathogenesis and clinical picture, ocular allergies are classified into mild forms, such as seasonal and perennial allergic conjunctivitis as well as giant papillary conjunctivitis, and chronic, potentially blinding forms such as atopic keratoconjunctivitis and vernal keratoconjunctivitis. New therapeutics act on the entire inflammatory process or try to modulate the allergic reaction early and specifically. The association with non-ocular allergic symptoms requires an interdisciplinary approach.

Pseudogerontoxon

Pseudogerontoxon is a lesion that resembles a small segment of arcus senilis or gerontoxon and is seen in many individuals with limbal vernal or atopic keratoconjunctivitis. It is an important clinical finding because pseudogerontoxon is often times the only clinical evidence of previous allergic eye disease. To the authors' knowledge, pseudogerontoxon has only rarely been mentioned, and has never been pictured, in the peer-reviewed literature. Three examples are presented of this important clinical entity.

Animal models of allergic and inflammatory conjunctivitis

Allergic eye diseases are complex inflammatory conditions of the conjunctiva with an increasing prevalence and incidence. The diseases are often concomitant with other allergic diseases such as allergic rhinitis, atopic dermatitis and allergic asthma. Despite the disabling and prominent symptoms of ocular allergies, they are less well studied and further insights into the molecular basics are still required. To establish new therapeutic approaches and assess immunological mechanisms, animal models of ocular allergies have been developed in the past years. The major forms of allergic ocular diseases, seasonal and perennial allergic conjunctivitis, vernal and atopic keratoconjunctivitis and giant papillary conjunctivitis, each have different pathophysiological and immunological components. In contrast to these distinct entities, the current animal models are based on the sensitization against a small number of allergens such as ovalbumin, ragweed pollen or major cat allergens and consecutive challenge. Different animal species have been used so far. Starting with guinea-pig models of allergic conjunctivitis to assess pharmacological aspects, new models including rats and mice have been developed which mimic major features of ocular allergy. The presently preferred species for the investigation of the immunological basis of the disease is represented by murine models of allergic conjunctivitis. In the future, combined ocular, nasal and aerosolic challenges with allergens may provide a model of allergy that encompasses simultaneously the target organs eye, nose and airways with conjunctivitis, rhinitis and asthma.

Allergic chronic inflammation of the ocular surface in vernal keratoconjunctivitis

PURPOSE OF REVIEW

The purpose of this review is to describe the new immunopathologic features of vernal keratoconjunctivitis: the involvement of cytokines, growth factors, cells, mediators and neurotransmitters, as well as the mechanism leading to tissue remodelling.

RECENT FINDINGS

Vernal keratoconjunctivitis is an allergic eye disease affecting young boys living in a warm climate. It is characterized by conjunctival giant papillae, hyperemia and frequent involvement of the cornea. Approximately 50% of the patients with vernal keratoconjunctivitis do not have a family or medical history of atopic diseases, and do not show IgE sensitization, suggesting that this disease is not solely IgE mediated. Vernal keratoconjunctivitis is a Th2 lymphocyte driven disease with a Th2 cytokine derived pattern, increased levels of mRNA for IL-3, IL-4, IL-5 and IL-13. Th2 lymphocytes induce IgE hyperproduction, activation of mast cells, eosinophils, neutrophils and their toxic products. An overexpression of adhesion molecules, RANTES, eotaxin and metalloproteinases contribute to chronic inflammation. A role for substance P and nerve growth factor has been postulated, as well as for other growth factors (epidermal growth factor, fibroblast growth factor and transforming growth factor beta 1) that induce fibroblast growth and new collagen production. Recent studies have also pointed out the role of resident conjunctival cells, such as epithelial cells and fibroblasts, in the inflammatory and remodelling process of vernal keratoconjunctivitis. The pathogenesis of the condition is probably multifactorial, with the interaction of the immune, nervous and endocrine systems.

SUMMARY

Vernal keratoconjunctivitis is a chronic inflammatory and potentially blinding disease. Understanding of the complex interactions and cross talk between cells, cytokines and other mediators is relevant for new therapeutic approaches.