Case series of 406 vernal keratoconjunctivitis patients: a demographic and epidemiological study

Corticosteroid-sparing topical treatment with cyclosporin for juvenile keratoconjunctivitis

Ocular surface inflammation due to allergy and blepharitis can lead to corneal complications and visual impairment. The aim of this study is to evaluate the efficacy of a cyclosporin 0.1% topical treatment achieving steroid-sparing. Eighty pediatric patients with moderate and severe vernal and blepharitis-related keratoconjunctivitis were included. Symptoms (photosensitivity, itching, discharge, tearing), signs (corneal fluorescein staining, papillary hypertrophy) and patients' subjective assessment were evaluated during a 6-month follow-up. At the follow-up, all patients treated with topical cyclosporin showed a significant improvement in all subjective symptoms and objective signs (p < 0.001). The total number of courses of rescue steroids courses decreased from 3.71 ± 1.72 to 0.25 ± 0.49 at month 3 and to 0.13 ± 0.38 dropping bottle at month 6 (p < 0.001 at both time points). The 96.1% of the allergic cohort and 96.4% of the blepharitis cohort experienced a satisfactory good or rapid and good effect during the 6-month follow-up. The probability of needing rescue corticosteroids increased with an odds ratio of 1.98, (95% CI: 1.19-3.28, p = 0.008) for each unit increase in Oxford score when analysing the whole cohort. Topical cyclosporin seems to be very effective reducing the number of recurrences of corneal involvement and the need for steroid treatment.

Insights from 1096 clinical cases: pioneering a universal grading system for vernal keratoconjunctivitis management

AIM

To analyse the clinical and demographic profiles of patients with vernal keratoconjunctivitis (VKC) and propose a grading for VKC based on corneal status and symptom periodicity rather than disease activity.

METHODS

Retrospective observational study from January 2015 to January 2020 in India. VKC grading was based on past/present clinical signs and frequency of symptoms rather than disease activity. The electronic medical records were screened and details of VKC patients diagnosed by cornea specialists were recorded and analysed.

RESULTS

1096 VKC patients with a mean age of onset of 7.05±5.3 with 8.39% having adult onset were analysed. Symptoms included; itching (50.55%) and decreased vision (15.44%). Mixed VKC (52.04%) was the most common presentation with 49.1% having active disease. Complications included; keratoconus (18.43%), steroid-induced cataract (11.41%), glaucoma (10.95%) and limbal stem cell deficiency (5.29%). Dual-acting antiallergics (69.39%) were most commonly used, followed by topical immunomodulators.The patients were graded as, grade I: mild-presence of mild and seasonal symptoms and/or signs. Grade II: moderate-presence of persistent symptoms/and/or signs without corneal involvement. Grade III: severe-chronic persistent symptoms/and/or intermittent signs with corneal involvement or asymptomatic to mild symptoms with corneal pathognomonic signs. Grade IV: very severe-chronic persistent symptoms and/or corneal pathognomonic signs or active involvement/complication or asymptomatic with complications.

CONCLUSION

VKC is a chronic disease that often causes visual complications. The new grading system based on the cornea status and symptom periodicity rather than disease activity might help plan the management better.

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.

Seeing eye to eye: a modified Delphi method-based multidisciplinary expert consensus on the diagnosis and treatment of vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a chronic, recurrent, inflammatory disease that affects both eyes, often with asymmetric severity, potentially causing major visual complications. The seasonal management of VKC can be challenging, especially when specialists with different diagnostic and therapeutic approaches need to be consulted. The aim of this expert panel was to reach a national consensus among pediatric allergologists and ophthalmologists on the diagnosis and treatment of VKC. This consensus was developed by an expert panel of 17 Italian pediatric allergologists and ophthalmologists with over a decade of experience. Ten statements on VKC diagnosis and treatment formulated after a thorough review of current literature were evaluated by the panelists. The level of agreement was quantitatively assessed using a 5-point Likert scale. Consensus was reached if ≥ 75.0% of panelists agreed to any given statement. The consensus emphasizes the importance of evaluation by multispecialty reference centers or experienced specialists for accurate diagnosis. Prompt diagnosis, especially during active phases, is crucial and should occur before corticosteroid therapy. The Bonini score from 2007 is the preferred tool for VKC assessment, although future revisions may be considered. Short cycles of topical corticosteroids should be preferred over prolonged use, even during immunomodulatory therapy. When cyclosporine fails, tacrolimus should be considered.

CONCLUSION

This is the first consensus on the management of VKC that has gathered the expert opinions of both pediatricians and ophthalmologists. The outcome of this multidisciplinary effort provides a uniform approach to VKC diagnosis and treatment, thereby facilitating patient management across the country.

WHAT IS KNOWN

• Vernal keratoconjunctivitis (VKC) is a chronic recurrent ocular disease particularly prevalent in the pediatric population. • Despite its relevance, there is a lack of standardized approaches shared between pediatricians and ophthalmologists, leading to notable variations in clinical practice.

WHAT IS NEW

• This expert panel, comprising 17 pediatric allergologists and ophthalmologists, has reached a national consensus to provide standardized guidance for VKC management. • The consensus emphasizes the importance of a multidisciplinary approach to managing VKC, ensuring consistent and effective patient care.

Serum vitamin D levels in children with vernal keratoconjunctivitis - A study from a tertiary care pediatric hospital of North India

BACKGROUND

To study the levels of vitamin D serum levels in children with vernal keratoconjuctivits (VKC) and comparing vitamin D levels in after giving vitamin D supplements between intervention and control group.

METHODS

The study was conducted in population between 1 to 12 years in tertiary care hospital in North India. Amongst children with VKC, full ocular examination along with Boninis clinical grading of VKC and serum vitamin D levels were assessed. Whole study group was randomly divided into two groups. Intervention group had received vitamin D powder while control group kept under observation.

RESULTS

A total of 88 children received vitamin D supplementation and 39 kept in control group.

CONCLUSION

Our study suggests that children in intervention group showed improvement in serum vitamin D levels with the clinical improvement in VKC grading too.

Characteristics of Vernal Keratoconjunctivitis in Lhasa: A Single-Center, Observational Study

The incidence of vernal keratoconjunctivitis (VKC) varies across different ethnicities and regions. To investigate the clinical features of VKC in Tibet, a single-center case series of VKC was retrospectively reviewed from a general hospital in Lhasa over one year. General data and typical manifestations were recorded. Horner-Trantas dots, limbal neovascularization, pseudogerontoxon and upper palpebral conjunctival papilla were seen in most of these patients. Patients with signs such as limbal pannus (t = 2.18, P < 0.05), pseudogerontoxon (t = 2.61, P < 0.05), and Horner-Trantas dots (t = 2.33, P < 0.05) appeared to have longer disease courses, while patients with upper palpebral conjunctival lesions had earlier onset times (t = 2.12, P < 0.05). The clinical signs of VKC on the Tibetan Plateau are more obvious, and the ocular surface is commonly and severely involved.

Development and validation of a health practitioner survey on ocular allergy

Survey studies have played a significant role in understanding the gaps in the knowledge and practices of health practitioners. However, there have been no such survey studies on Ocular Allergy (OA). Thus, the purpose of this study was to develop and validate a survey on OA to better understand the gaps in the diagnostic, treatment, and collaborative care approaches of health practitioners in OA. The survey is titled "Survey on Ocular Allergy for Health Practitioners (SOAHP)". SOAHP was developed in a five-stage process. First, item extraction via the use of a literature review, second, face and content validity, third, a pilot study, fourth, test-retest reliability, and fifth, finalisation of the survey. 65 items under 6 domains were initially generated in the item extraction phase. Content validity was conducted on 15 experts in the field. This was conducted twice to reach consensus whereby items and domains were added, edited, kept, or removed, resulting in 50 items under 7 domains. The pilot study was conducted on 15 participants from the five relevant health practitioner fields (Allergists/Immunologists, General Practitioners (GPs), Ophthalmologists, Optometrists and Pharmacists). This altered the survey further to 40 items under 7 domains. Test-retest reliability was conducted on 25 participants from the five health practitioner fields. Reliability was moderate to almost perfect for most (97%) investigated items. The finalised survey was 40 items under 7 domains. SOAHP is the first survey created to assess diagnostic, treatment and collaborative care approaches of Allergists/Immunologists, GPs, Ophthalmologists, Optometrists and Pharmacists on OA. SOAHP will be a useful tool in clinical research on OA.

Vernal keratoconjunctivitis in adults: a narrative review of prevalence, pathogenesis, and management

Vernal keratoconjunctivitis (VKC) is a chronic, progressive, allergic ocular surface disorder that can lead to sight-threatening complications. VKC occurs primarily in children and generally resolves about the time of puberty; however, case series and retrospective analyses indicate that approximately 10% of patients with VKC are adults, and that a subset of adult cases develop after puberty. Consequently, two age-related variants of VKC have recently been described: early-onset VKC-which manifests during childhood and persists into adult life-and late-onset disease, which emerges de novo after puberty. Although the signs and symptoms of adult and childhood VKC are similar, adult VKC is a long-lasting disease characterized by severe inflammation and increased risk of conjunctival fibrosis, which may place adult patients at higher risk for sight-threatening complications and adverse impacts on daily life. This review discusses the epidemiology, signs, symptoms, immunopathogenesis of adult VKC variants, and highlights current gaps in research and management of patients with this condition.

Vernal keratoconjunctivitis and eosinophilic esophagitis: A rare combination?

Vernal keratoconjunctivitis (VKC) is a bilateral ocular inflammatory disease with a conjunctival and corneal involvement and typical onset during childhood. Eosinophilic esophagitis (EoE) is a chronic disease characterized by eosinophilic inflammation of the mucosa (≥15 eosinophils/HPF) and symptoms of esophageal dysfunction. EoE and VKC are both immune-mediated diseases sharing a similar pathogenetic mechanism and a high association with other allergic diseases. Nevertheless, no data are currently available about their clinical association. We present 4 cases of concomitant diagnosis of vernal keratoconjunctivitis and eosinophil esophagitis suggesting that these conditions may coexist in the same patient more frequently than expected. Health care providers should be aware of the possibility of co-occurrence in their daily practice.

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.

Two cases of unilateral limbal Vernal keratoconjunctivitis in the same family: first case report

This case report describes two cases of unilateral limbal Vernal keratoconjunctivitis (VKC) in the same family. To our knowledge, these are the first two reported cases of unilateral limbal VKC. VKC is a chronic inflammatory disease that typically affects both eyes, with unilateral cases being rare and previously only reported in the tarsal form. Our first case involved a 12-year-old girl with a history of allergic asthma, who had been experiencing conjunctivitis in her right eye since the age of 7. Upon examination, she was diagnosed with unilateral limbal VKC and treated with 1% cyclosporine eye drops with a significant improvement observed at the one and three-month follow-ups. Her 7-year-old brother was also examined and found to have unilateral limbal VKC in his right eye, although it was milder and not associated with allergic pathogenesis. Therefore, in this case, a treatment with hydrocortisone eye drops was started leading to an immediate reduction of the itching. In both cases an IgE-mediated mechanism is less likely because of the monolateral eye involvement, the complete absence of nasal symptoms, the lack of correlation between symptoms and any pollen season, and the negative prick skin test in one of the two siblings. Both cases suggest that unilateral VKC may occur even in the limbal form and that genetic mechanisms may contribute to the inflammatory reaction in VKC. This report highlights the need for further studies to explain the occurrence of unilateral VKC cases and reminds clinicians to consider the possibility of unilateral limbal VKC in pediatric patients.

Diagnostic criteria of chronic conjunctivitis: atopic keratoconjunctivitis and vernal keratoconjunctivitis

PURPOSE OF REVIEW

Chronic ocular allergies, vernal (VKC) and atopic keratoconjunctivitis (AKC) are relatively rare conditions that require definite diagnostic criteria to the most appropriate therapeutical approach.

RECENT FINDINGS

The diagnosis of both VKC and AKC is generally based on clinical history, signs and symptoms, and the results of allergic tests, which allow to identify the different diseases phenotypes. However, other subtypes of the two diseases and/or overlaps may occur making the diagnosis non always so clear, such as VKC and AKC overlaps or adult-like VKC disease. Each of these phenotypes may be sustained by different mechanisms which are still not well defined but not only related to a type 2 inflammation. The further challenges will be to correlate clinical or molecular biomarkers to a single subtype or disease severity.

SUMMARY

Definite criteria of chronic allergies will further guide to more specific therapeutical approaches.

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.

TFOS Lifestyle Report: Impact of environmental conditions on the ocular surface

Environmental risk factors that have an impact on the ocular surface were reviewed and associations with age and sex, race/ethnicity, geographical area, seasonality, prevalence and possible interactions between risk factors are reviewed. Environmental factors can be (a) climate-related: temperature, humidity, wind speed, altitude, dew point, ultraviolet light, and allergen or (b) outdoor and indoor pollution: gases, particulate matter, and other sources of airborne pollutants. Temperature affects ocular surface homeostasis directly and indirectly, precipitating ocular surface diseases and/or symptoms, including trachoma. Humidity is negatively associated with dry eye disease. There is little data on wind speed and dewpoint. High altitude and ultraviolet light exposure are associated with pterygium, ocular surface degenerations and neoplastic disease. Pollution is associated with dry eye disease and conjunctivitis. Primary Sjögren syndrome is associated with exposure to chemical solvents. Living within a potential zone of active volcanic eruption is associated with eye irritation. Indoor pollution, "sick" building or house can also be associated with eye irritation. Most ocular surface conditions are multifactorial, and several environmental factors may contribute to specific diseases. A systematic review was conducted to answer the following research question: "What are the associations between outdoor environment pollution and signs or symptoms of dry eye disease in humans?" Dry eye disease is associated with air pollution (from NO2) and soil pollution (from chromium), but not from air pollution from CO or PM10. Future research should adequately account for confounders, follow up over time, and report results separately for ocular surface findings, including signs and symptoms.

An observational study on the presence of perilimbal conjunctival pigmentation in vernal keratoconjunctivitis

Purpose

To evaluate presence of perilimbal pigmentation (PLP) in Indian patients with vernal keratoconjunctivitis (VKC). Methods: A cross sectional study was conducted from 2019 to 2020 at a tertiary eye care center in Western Maharashtra, India. In this study, 152 cases of VKC were identified. The presence, type, color, and extent of PLP were recorded. The incidence of presence of PLP was calculated. Its correlations with severity and duration of VKC were analyzed using Wilcoxon-Mann-Whitney U test and Chi square test.

Results

Of 152 cases, 79.61% were males. Mean age at presentation was 11.4 ± 5.6 years. The characteristic PLP was present in 81 cases (53.29%; 95% confidence interval [CI]: 45.03%-61.42%; P < 0.001), of which 15 cases (18.5%) had this pigmentation in all the four quadrants. There was a significant difference between the groups with respect to quadrants involvement in terms of the extent of PLP in clock hours (χ² = 73.85, P < 0.001). However, the extent did not correlate with age (rho = 0.08, P = 0.487), sex (P = 0.115), time since onset in months (rho = 0.03, P = 0.77), duration of VKC and type or color of PLP (P = 0.12).

Conclusion

Perilimbal pigmentation seems to be a consistent clinical finding seen in a significant number of VKC cases. It may benefit ophthalmologists in treating VKC cases when the palpebral/limbal signs are elusive.

Prevalence of allergic sensitization with vernal keratoconjunctivitis: A systematic review with meta-analyses

To determine the prevalence of allergic sensitization in patients with vernal keratoconjunctivitis (VKC) and to provide an overview of published studies on this topic. We systematically searched 11 literature databases on 24 May 2021, for studies with cross-sectional data on the prevalence of positive allergy tests in patients with VKC. Our main outcome of interest was the prevalence of allergic sensitization and the allergens involved. Prevalence meta-analyses were made to provide summary estimates. We identified 33 eligible studies for qualitative review with 2122 patients with VKC. Studies were predominantly based on patients seen in ophthalmology clinics. Overall, studies reported that the most prevalent positive allergen tests were the inhaled allergens house dust mites and pollen. Twenty-nine studies were eligible for the quantitative analysis. Here, we calculated the prevalence of allergen-positive patients to 57.7% (95% confidence interval: 52.5%-62.8%). Subgroup analyses of pooled estimates on sensitization based on specific testing methods found prevalence estimates of 51.4% for conjunctival provocation test, 68.7% for total tear IgE, 58.9% for specific tear IgE, and 58.2% for skin prick test. The prevalence of allergic sensitization in patients with VKC is 57.7%, and mostly towards inhaled allergens. The most frequent positive allergens are house dust mites and pollen. Identifying possible clinically relevant allergens provide information that may aid in managing VKC, such as environmental allergy-avoidance or allergy-specific treatment.

Comparision of efficacy and safety of 0.03% and 0.1% tacrolimus ointment in children with vernal keratoconjunctivitis

Background

Topical immunosuppressants such as tacrolimus in different concentrations are a breakthrough in the management of recalcitrant vernal keratoconjunctivitis (VKC); however, there is a lacks of comparative studies to guide their use in VKC management.

Objective

To compare the efficacy and safety of tacrolimus 0.03% and 0.1% eye ointment in the treatment of recalcitrant VKC.

Design

A retrospective comparative single-centre observational study.

Method

We reviewed records of a total of 48 recalcitrant VKC patients treated with two different strengths of tacrolimus ointment between April 2016 and March 2017. Of these, 39 fulfilled the inclusion criteria and were categorized into two groups, A and B, depending on the use of strength of tacrolimus (0.03% and 0.1%) used, respectively. Group A had 18 patients, while group B had 21 patients. Thirty-six patients, 18 from each group, were finally analysed and compared. Records of patients were explored for the subjective symptoms and objective sign score of the patient at baseline and at each time point. The main outcome measures were composite scoring and comparison of total subjective symptom scores (TSSSs) and total objective sign scores (TOSSs) within and between the groups at each follow-up. Percentage of patient with significant reduction in symptom and sign scores as compared with baseline was considered success of treatment. Chi-square and t-tests were used for comparison of outcomes between both groups.

Results

Mixed variety was most commonly encountered type of VKC. The signs and symptoms were significantly reduced in patients with treatment in both groups (p = 0.001) in all types of VKC. However, in group B, there was significant improvement in the size of papillae (p = 0.04) as compared baseline in contrast to group A. Side effects like burning and stinging in group B were significantly higher as compared with group A.

Conclusions

Both strengths of tacrolimus (0.03% and 0.1%) are effective in all forms of recalcitrant VKC. Papillary component of VKC responds better with higher strength (0.1%) but is associated with more significant side effects. Different strengths of tacrolimus can be used strategically depending upon the severity and clinical type of VKC to intensify outcome and minimize side effects.

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

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

Treating Severe Pediatric Keratoconjunctivitis with Topical Cyclosporine A

The incidence of chronic keratoconjunctivitis, which potentially causes long-term loss of visual acuity due to corneal opacity, is considerably less common in children than in adults. It is therefore in danger of being overlooked. In children the appropriate treatment is therefore often introduced too late, or to an insufficient extent. In this article we would like to raise awareness about the diagnosis of chronic keratoconjunctivitis in children, and to present an effective treatment plan for severe stages of the disease. There are two forms of chronic keratoconjunctivitis that occur most frequently in children: hyperergic blepharokeratoconjunctivitis (hBKC) and vernal keratoconjunctivitis (VKC). With hBKC, the patient often has a history of recurring hordeolum and also presents with blepharitis; it is characterized by the marked presence of corneal neovascularization in the lower circumference of the cornea. VKC is typically characterized by changes under the upper eyelid, with marked changes to the superior limbus. If there is a risk of complications involving the cornea, or in the presence of such complications, a consistent long-term topical immunosuppressive and anti-inflammatory treatment is required. Both of these properties are combined in the active ingredient cyclosporine A. Other advantages of topical CSA treatment are its steroid-sparing effect and the long-term reduction of exacerbations. Parents need to be informed about the chronic nature of these two diseases and their tendency to recur; because of these characteristics, treatment, in most cases, should be envisaged for at least one year in order to effectively disrupt the complex immunologic processes. This safeguards the child's visual development and prevents amblyopia caused by scarring and astigmatism. We hope that the data presented will lower the barriers related to prescribing CSA for topical eye application in children.

The effects of the COVID-19 pandemic on the treatment of allergic eye diseases

PURPOSE OF REVIEW

To analyze if recommendations given before and during the COVID-19 pandemic are still a valid option for patients suffering of ocular allergy (OA).

RECENT FINDINGS

During the last year many doctors and patients requested suggestions for the treatment of OA patients in COVID-19 time. Most of them were given by phone calls and emails following the recommendations given by Scientific Societies.

SUMMARY

Considering the current multiple problems related to the COVID-19 pandemic, OA has not been considered a priority, even though patients need treatments. Topical antiallergic drugs are still the first option to treat all kind of OA, with the addition of topical corticosteroids in the severe forms of vernal and atopic keratoconjunctivitis (VKC and AKC) even in patients at risk of COVID-19. Topical immunomodulation is still recommended in severe forms of VKC and AKC unless the patient is infected. The number of patients treated with these drugs in our Center was similar than previous years. The risk to have a VKC patient affected by COVID-19 is similar to the general pediatric population but with a lower OR. In 2021, still in COVID-time, the management of OA should follow the previous recommendations with an update due to the risk of infection.

Psychosocial impact of ocular surface allergic inflammatory disorders

PURPOSE OF REVIEW

Allergic rhinoconjunctivitis is one of the most common ocular surface allergic inflammatory conditions seen in primary care that impacts patient's quality of life. Allergic conjunctivitis is increasingly being recognized as its own symptom complex that negatively impacts patient's quality of life separate from allergic rhinitis. This article reviews the psychosocial impact of ocular surface allergic inflammatory disorders (namely seasonal allergic conjunctivitis, ocular allergy, perennial allergic conjunctivitis, and atopic keratoconjunctivitis) on adult and pediatric populations.

RECENT FINDINGS

Despite the perception that allergic conjunctivitis is a trivial condition, it imposes a burden on numerous psychosocial aspects of life for adolescents and adults. Several questionnaires specific to rhinoconjunctivitis have been found to be effective tools at gauging quality of life (QoL) and communicating impairments in specific behavioral domains for adult and pediatric populations. An emerging focus on the role of hormone fluctuations and age on ocular surface allergic inflammation underscores the importance of nuancing the physiologic effects on ocular allergy and QoL at every decade of life.

SUMMARY

Further exploration and research of symptoms by age would greatly improve our understanding of age's impact on QoL in these patients and contribute to improved management of allergic conjunctivitis.

Understanding Vernal Keratoconjunctivitis: Beyond Allergic Mechanisms

Vernal keratoconjunctivitis (VKC) is a chronic, recurrent, inflammatory disease of the cornea and conjunctiva mostly affecting boys in prepubertal age. VKC recurrence is characterized by intense symptoms of itching, redness, and photophobia associated with corneal damage, impairment of visual function, and quality of life. The pathogenesis of VKC has not yet been completely understood, and it is still controversial. In fact, VKC is considered an ocular allergic disease due to the involvement of immunoglobulin E, eosinophils, and mast cells, and of a lymphocyte T-helper type 2 reaction. However, approximately half of VKC patients have negative allergological history and testing, suggesting that other pathogenic mechanisms participate in VKC development and severity. Specifically, evidence suggests that genetic, endocrine, neuronal factors and an imbalance of innate immunity are involved in the pathogenesis of VKC. The purpose of this review is to summarize evidence on the pathogenic role of innate immunity, neuroimmune reaction, and hormonal changes in VKC. Increasing understanding of the pathogenic mechanisms behind VKC may lead to the identification of novel biomarkers for diagnosis and/or potential therapeutic targets in order to improve the management of this challenging condition.

Adult vernal keratoconjunctivitis

PURPOSE OF REVIEW

Vernal keratoconjunctivitis (VKC) is a rare chronic self-limiting allergic inflammatory disease of the ocular surface mostly affecting young boys in their first decade of life. In the last few years a new clinical entity of VKC has been described: adult VKC. Two variants have been identified according to clinical onset: early (childhood VKC persisting beyond puberty) and late onset (arising de novo in adults) adult VKC. Several epidemiologic studies on VKC have been published from single tertiary centers but while the age distribution of VKC patients does show a small percentage of adults with the disease, detailed analysis on this small subset of adult VKC cases is lacking. In this review we describe pathogenesis, clinical features, diagnostic alternatives, and therapeutic alternatives of this highly invalidating disease.

RECENT FINDINGS

Adult variants of VKC have same clinical manifestations of classic form, but show higher inflammatory response and increased risk of chronic fibrotic sequelae.

SUMMARY

Adult VKC research could provide insights on the impact of sex hormones in the pathogenesis of allergic diseases and on the mechanisms of inflammation and fibrosis, which cause potentially vision threatening sequelae. The present review will highlight the recent developments in our understanding of this uncommon entity.

Health-related quality of life in children at the diagnosis of Vernal Keratoconjunctivitis

BACKGROUND

Vernal keratoconjunctivitis (VKC) is a bilateral, chronic, allergic condition mostly affecting children. Clinical evaluations may not necessarily reflect the impact of the disease on the patients' health-related quality of life (HRQoL). We aimed to evaluate HRQoL in children at VKC diagnosis and to analyze correlations between HRQoL and clinical and laboratory variables.

METHODS

We studied 5- to 12-year-old patients with VKC. Data on clinical history, instrumental eye evaluations, blood examinations, and visual analog scale (VAS) for the subjective symptoms were collected. HRQoL was assessed through a disease-specific validated Quality of Life in Children with Vernal Keratoconjunctivitis (QUICK) questionnaire.

RESULTS

Seventy subjects were included in the analysis (female/male: 10/60; tarsal/mixed VKC form: 36/34). Clinical severity of VKC according to the Bonini scale was as follows: 14, mild; 36, moderate; and 20, severe. No significant difference was found concerning the distribution of patient age, gender, and history of allergic manifestations between tarsal and mixed VKC. A significant positive correlation was found between all QUICK scores and VAS scores, including different VAS subscale, while no significant correlation was found between QUICK scores and total sign scores, Schirmer's test, and corneal thickness. The presence of active severe VKC was not associated with worse HRQoL.

CONCLUSIONS

Our evidence shows that VKC patients experience impairment of HRQoL, especially in relation to the perception of symptoms independently of the ophthalmologic changes found, and that the QUICK questionnaire could be a useful tool to evaluate HRQoL in children with VKC, which may improve patients' classification and management.

Is Interferon α-2b 1 MillionIU/mL Truly Better Than Tacrolimus 0.03% for Steroid-Resistant VKC ?: Our 2-Year Experience at a Tertiary Health-Care Centre

Purpose

To compare the efficacy of eye-drop interferon (IFN) α-2b 1 millionIU/mL with eye-ointment tacrolimus 0.03% in refractory vernal keratoconjunctivitis (VKC).

Materials and Methods

Fifty patients with VKC refractory to conventional treatment with topical corticosteroids and antihistamines after 4 weeks of regular use were selected retrospectively. Patients were divided into two groups depending on whether they received eye-ointment tacrolimus 0.03% three times a day or eye-drop IFN alpha-2b 1 millionIU/mL three times a day and were followed up for 24 months. The main outcome measures were total subjective symptom score (TSSS) and total objective ocular score (TOSS).

Results

Mean baseline TSSS was 7.24±1.98 in Group A (tacrolimus group) and 7.84±1.82 in Group B (IFN group), and it reduced to 1.12±0.83 in Group A and 0.62±0.41 in Group B at 6 months, which was statistically significant compared to the baseline score (p<0.05) as well as between the two groups. Mean baseline TOSS was 6.72±2.07 in Group A and 6.56±2.04 in Group B, and it improved to 1 month onwards to 1.52±0.87 in Group A and 1.0±0.71 in Group B at 6 months, which was statistically significant compared to the baseline score (p<0.05) as well as between the two groups. Side effects like stinging and burning sensations were seen in the tacrolimus group only.

Conclusion

Our study suggests that while both eye-drop IFN α-2b 1 millionIU/mL and eye-ointment tacrolimus eye ointment 0.03% are both safe and effective steroid-sparing agents in steroid-resistant VKC. IFN α-2b results in greater improvement in subjective symptoms and objective signs, has fewer side effects in long term and is better tolerated as compared to tacrolimus.

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.

The role of human immunodeficiency virus in the pathogenesis of vernal keratoconjunctivitis-like disease in adults: A demographic and epidemiological study

Purpose:

The purpose was to identify and describe patients with new-onset vernal keratoconjunctivitis-like (VKC-like) disease after puberty.

Methods:

The study consisted of two parts: a prospective observational descriptive study of patients with new-onset VKC-like disease, and a case-control study to determine the relationship of a CD4 count with VKC-like disease in adults, in the setting of human immunodeficiency virus (HIV). Patients were recruited between January 2016 and November 2017 from a Provincial Eye hospital, one of two large referral hospitals in KwaZulu-Natal, South Africa. Patients presenting to the eye clinic were screened and diagnosed at the Primary Eye Care Unit. Inclusion criteria: age 15 years and older with signs and symptoms of new-onset VKC-like disease. Exclusion criteria: a history of childhood atopic diseases, atopic keratoconjunctivitis and patients who declined HIV testing. Data collected included HIV status, CD4 count, antinuclear antibodies and total serum immunoglobulin E.

Results:

Thirty-three patients were included; females n = 16 and males n = 17. The mean age at presentation was 32.45 ± 9.93 years, 95% CI = 28.94–35.97. Twenty-six patients (78.8%) were HIV positive, 95% CI (62–89). The proportion of HIV positive patients was statistically different from the HIV negative group, Chi-squared = 21.866, P value <0.0001. In the group of HIV positive patients, 72% were classified as immunodeficient according to their CD4 counts. An association was proven between severely immunodeficient patients and the risk of VKC-like disease (Chi-squared = 4.992, P value = 0.0255).

Conclusion:

In this cohort, a statistically significant association was found between VKC-like disease in adults and an HIV positive status. This association calls for more research on the subject.

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.

Epidemiology of rare allergic diseases in children

Allergic diseases have different frequencies. In particular, allergic rhinitis and asthma have high frequencies of about 20% and 10%, respectively. Other allergic diseases have lower frequencies; for example, food allergy has a frequency of 1%-4%. There are also rare allergic diseases, with a prevalence of 5 cases per 10 000 people in the general population, and they are included in Orphanet. However, other extremely rare allergic diseases still need to be properly known in order to be possibly recognized as rare diseases and cataloged in Orphanet.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Questionnaires Assessing the Quality of Life of Ocular Allergy Patients

Over the last 25 years, health-related quality of life has received increasing recognition, as it aids health practitioners in understanding the way a patient may be impacted by their health condition. Specifically, ocular allergy has been found to affect an individual emotionally, physically, socially, and economically. Hence, scientists have developed multiple questionnaires, based on the different etiologies of ocular allergy, to assess the quality of life of individuals affected by the condition. One highly regarded questionnaire is the Rhinoconjunctivitis Quality of Life Questionnaire and its variations, namely the Standardised Rhinoconjunctivitis Quality of Life Questionnaire, Mini Rhinoconjunctivitis Quality of Life Questionnaire, Nocturnal Rhinoconjunctivitis Quality of Life Questionnaire, Adolescent Rhinoconjunctivitis Quality of Life Questionnaire, and Paediatric Rhinoconjunctivitis Quality of Life Questionnaire. Other questionnaires include the Eye Allergy Patient Impact Questionnaire and the Quality of Life of Children with Allergic Keratoconjunctivitis questionnaire, among others that are suitable for different countries. The purpose of this commentary was to identify the advantages and disadvantages of each questionnaire by critically analyzing psychometric properties, identifying which ocular allergy domains are present, and evaluating additional features that are important to a questionnaire.

Stability and Safety Traits of Novel Cyclosporine A and Tacrolimus Ophthalmic Galenic Formulations Involved in Vernal Keratoconjunctivitis Treatment by a High-Resolution Mass Spectrometry Approach

In this study, a sensitive quantitative method based on high performance liquid chromatography combined with high-resolution mass spectrometry, Q Exactive^TM-Orbitrap^® was set up and applied for the determination of the immunosuppressor agents cyclosporine A and tacrolimus in novel ethanol-free ophthalmic formulations for the treatment of Vernal keratoconjunctivitis. Different storage parameters in terms of storage temperatures and practical usage conditions were investigated to assess the stability of all formulations during shelf life simulating the real conditions as well to confirm the feasibility of use of ethanol-free products. The methodology was linear (r² = 0.995) over the concentration range 0–200 ng/mL, and its selectivity, precision, accuracy and recovery were all within the required limits. Under different conditions (storage period 0–90 days, 5–25 °C, unopened/usage simulated conditions), our results revealed that both active pharmaceutical ingredients (API) show satisfactory stability up to 30 days of storage/usage, with a significant and consistent concentration decline of cyclosporine A after this time point when its hydroalcoholic formulation was kept at 25 °C.

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

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

Pattern of steroid misuse in vernal keratoconjunctivitis resulting in steroid induced glaucoma and visual disability in Indian rural population: An important public health problem in pediatric age group

Purpose

To know the pattern of presentations and management outcome of steroid induced glaucoma in vernal keratoconjunctivitis (VKC).

Methods

Children of VKC using steroid with two of the following criteria were enrolled: Intraocular pressure (IOP) >21 mm Hg, glaucomatous optic disc and visual field defects. Misused topical steroids were classified in 4 groups; A- Highly potent drugs (dexamethasone, betamethasone), B- Moderate (prednisolone), C- Weak (loteprednol, fluorometholone), D- Unknown drugs. Active/conservative interventions were done to control IOP. Corrected distance visual acuity (CDVA), IOP, anterior segment and fundus examinations were noted. One-way ANOVA test and post hoc Tukey HSD test were used to compare the groups.

Results

Out of 1423 VKC patients, 240 were using topical steroid without prescriptions. 92 eyes of 47 patients had steroid induced glaucoma. Hence prevalence of this complication was 3.30% in this study population. Mean age was 14.1 ± 3.8 years. Mean IOP was 38 ± 12 mm of Hg and mean vertical cup disc ratio was 0.67 ± 0.25. IOP was controlled by withdrawal of steroids (9 eyes), with antiglaucoma medications (27), trabeculectomy (57) and glaucoma drainage device (1). Mean CDVA at presentation was better in group C (0.23 log MAR). Mean IOP was highest in group A (43.1 mm Hg) followed by group D (40.5 mm Hg). At presentation 17 were blind (CDVA <3/60). Post treatment marginal improvement in CDVA was found (P = 0.46). However, statistically significantly improvement was noticed in IOP (P < 0.00001).

Conclusion

Injudicious use of steroids leads to vision threatening complications like ocular hypertension and glaucoma in children of VKC. Weak steroids like loteprednol or fluorometholone should be used instead of higher potency drugs. Vision and IOP should be monitored fortnightly in children using topical steroids to detect steroid responders at the earliest.

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

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

Efficacy of Houttuynia eye drops for the treatment of vernal keratoconjunctivitis: A systemic review and meta-analysis protocol

BACKGROUND

Vernal keratoconjunctivitis (VKC) is a common eye disease and can result in permanent decrease or loss of vision. Houttuynia eye drops (HED) is used for the treatment of VKC. However, the clinical evidence of HED has not been well concluded. Herein, we described a proposed systemic review and meta-analysis to evaluate the clinical efficacy of HED for the treatment of VKC.

METHODS

Six electronic databases (Medline, Embase, the Cochrane database, Chinese National Knowledge Infrastructure, Wanfang database, and Chinese Biology and Medicine database) will be searched for randomized controlled trials (RCTs) which evaluating the clinical efficacy of HED for the treatment of VKC. Studies meet the eligibility criteria will be included. Data of the included studies will be extracted and the quality will also be evaluated. Data synthesis will be performed using RevMan software. Sensitivity analysis and publication bias will also be investigated.

RESULTS

This study will provide high-quality systemic review and synthesis of RCTs on efficacy of HED for the treatment of VKC.

CONCLUSION

This systemic review and meta-analysis will conclude the efficacy of HED for the treatment of VKC.

REGISTRATION

PROSPERO CRD42019124737.

Diagnosing and managing allergic conjunctivitis in childhood: The allergist's perspective

Allergic conjunctivitis in childhood often poses problems of diagnosis and management for the allergist. We present the salient points concerning the diagnosis and treatment of ocular allergy emerging from a large cohort survey conducted jointly in the departments of ophthalmology and paediatric allergy in a French teaching hospital. Seasonal acute conjunctivitis is a common disorder and not overly difficult to diagnose and treat when associated with rhinitis leading to allergic rhinoconjunctivitis. An ophthalmologist should be consulted when conjunctivitis occurs alone and if another form of conjunctivitis is suspected, such as perennial allergic conjunctivitis, vernal keratoconjunctivitis or atopic keratoconjunctivitis. When IgE-mediated hypersensitivity assessment does not establish aetiological diagnosis, a conjunctival allergen provocation test can be performed. The principal non-IgE-mediated allergy is chronic blepharoconjunctivitis. The main problem for differential diagnosis is the presence of signs suggestive of dry eye. Management includes non-pharmacological treatments, such as lacrimal substitutes, avoidance measures and protection of the ocular surface. Second-line treatment consists of eye drops, preferably single dose or without additives and with dual local action, mast cell stabilizer action and antihistaminic action. Third-line treatment is reserved for severe forms. Short-lasting local steroid therapy can control flare-ups of allergic keratoconjunctivitis, which should have specialized follow-up. Cyclosporine is a disease-modifying treatment, which is both effective and well tolerated.

Vernal Keratoconjunctivitis: an update focused on clinical grading system

INTRODUCTION

Vernal keratoconjunctivitis (VKC) is a severe disease with a prevalence of < 1 case out of 10,000 in Europe, which occurs mainly in pediatric age and is characterized by a severe and often bilateral chronic inflammation of the ocular surface. The diagnosis is generally confirmed by the finding at the ocular examination of conjunctival hyperemia, papillary hypertrophy in the tarsal conjunctiva, giant papillae, papillae in the limbus region.

OBJECTIVE

Aim of this review is to provide an updated overview on the disease focused on clinical grading system, searching papers published in the last decade on VKC in scientific databases.

RESULTS

Currently there are no standardized criteria for diagnosis of VKC and there is no uniformity to define disease severity, which makes difficult to diagnose and treat the disease.

CONCLUSIONS

Given the wide overlap of the symptoms of VKC with the allergic conjunctivitis, criteria of probable, possible or improbable diagnosis are needed, providing pediatricians with parameters useful for deciding whether to drive the patient to the ophthalmologist for diagnostic confirmation.

Steroid-induced glaucoma and blindness in vernal keratoconjunctivitis

PURPOSE

To report the clinical features, treatment outcomes and blindness associated with steroid-induced glaucoma in vernal keratoconjunctivitis (VKC).

MATERIALS AND METHODS

Records of patients with VKC, who visited our tertiary centre from 1992 and 2009, were reviewed and those with steroid-induced glaucoma were included in the study. Glaucoma was diagnosed based on intraocular pressure (IOP) ≥22 mm Hg on two consecutive visits (ocular hypertension) and/or glaucomatous optic disc damage. Blindness was defined as best corrected visual acuity of ≤20/400 or visual field <10°.

RESULTS

Of the 4062 VKC subjects, 91 (157 eyes) had steroid-induced glaucoma (SIG), showing a prevalence of 2.24%. Of these 87% were men. The median (IQR) age at onset of VKC was 12 years (7-17). At presentation, the median duration of VKC was 48 months (24-72) and the median duration of steroid usage was 24 months (12-36). The median cup-to-disc ratio (CDR) was 0.9 (0.7-0.9) and median mean deviation was -21.9 dB (-30.0 to -10.2). IOP was medically controlled in 66% eyes (104/157) and 34% eyes (53/157) needed glaucoma surgery. High presenting IOP (OR: 1.04; p=0.05) and increased duration of steroid usage (OR: 1.07; p=0.02) were significantly associated with need for glaucoma surgery. At presentation, 29/91 subjects (31.8%) were bilaterally blind due to SIG. Higher CDR at presentation was significantly associated with blindness in this cohort (p=0.02).

CONCLUSION

In this cohort of VKC with SIG, the disease predominantly affected adolescent males. Glaucoma was severe with one-third needing surgery and one-third blind due to SIG.