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

Vernal Keratoconjunctivitis: A Systematic Review

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

Injection of Botulinum Toxin A in the Lacrimal Gland for Treatment of Epiphora in Crocodile Tears Syndrome – A Case Report

Purpose

Crocodile tears syndrome is a rare autonomic synkinesia, in which patients tear excessively in response to salivary stimuli. It usually occurs after idiopathic or traumatic facial palsy, as a result of aberrant reinnervation of the lacrimal gland by salivary efferent fibers from either the seventh or ninth cranial nerve.

Patients and Methods

We report the case of a 54-year-old woman, with a history of left Bell’s palsy, who attended our ophthalmology clinic due to epiphora of the left eye while eating or speaking, for 6 months.

Results

The ophthalmologic evaluation revealed a mild weakening of the frontal and left orbicularis oculi muscles without lagophthalmos. No other abnormalities were found, namely ocular surface swelling, ectropion, or obstruction of the lacrimal outflow system. Schirmer test II in the left eye increased from 12 to 23 mm while the patient was chewing. All these clues led to the diagnosis of crocodile tears syndrome and treatment with botulinum toxin A injection was proposed. One month after the injection of the palpebral lobe of the left lacrimal gland with 6 units of botulinum toxin A, the patient reported an almost complete resolution of the complaints, stated by a decrease in Munk scale and Lac-Q scores. Six months after injection, the patient conveyed recurrence of symptoms and a new treatment session was performed with comparable results.

Conclusion

Since crocodile tears syndrome is rare, it is crucial to increase awareness and knowledge about it among ophthalmologists and other medical doctors. Botulinum toxin is a safe and effective treatment modality, dramatically improving these patients’ quality of life.