Endoplasmic Reticulum Stress and Unfolded Protein Response in Vernal Keratoconjunctivitis

Purpose

Vernal keratoconjunctivitis (VKC) is an ocular allergic disease characterized by a type 2 inflammation, tissue remodeling, and low quality of life for the affected patients. We investigated the involvement of endoplasmic reticulum (ER) stress and unfolded protein response in VKC.

Methods

Conjunctival imprints from VKC patients and normal subjects (CTs) were collected, and RNA was isolated, reverse transcribed, and analyzed with the Affymetrix microarray. Differentially expressed genes between VKC patients and CTs were evaluated. Genes related to ER stress, apoptosis, and autophagy were further considered. VKC and CT conjunctival biopsies were analyzed by immunohistochemistry (IHC) with specific antibodies against unfolded protein response (UPR), apoptosis, and inflammation. Conjunctival fibroblast and epithelial cell cultures were exposed to the conditioned medium of activated U937 monocytes and analyzed by quantitative PCR for the expression of UPR, apoptosis, autophagy, and inflammatory markers.

Results

ER chaperones HSPA5 (GRP78/BiP) and HYOU1 (GRP170) were upregulated in VKC patients compared to CTs. Genes encoding for ER transmembrane proteins, PKR-like ER kinase (PERK), activating transcription factor 6 (ATF6), ER-associated degradation (ERAD), and autophagy were upregulated, but not those related to apoptosis. Increased positive reactivity of BiP and ATF6 and unchanged expression of apoptosis markers were confirmed by IHC. Cell cultures in stress conditions showed an overexpression of UPR, proinflammatory, apoptosis, and autophagy markers.

Conclusions

A significant overexpression of genes encoding for ER stress, UPR, and pro-inflammatory pathway components was reported for VKC. Even though these pathways may lead to ER homeostasis, apoptosis, or inflammation, ER stress in VKC may predominantly contribute to promote inflammation.

Analysis of the outcomes of three different cross-linking protocols for treatment of paediatric keratoconus: A multicentre randomized controlled trial

PURPOSE

To analyse long-term outcomes of standard cross-linking (SCXL), accelerated cross-linking (ACXL) and transepithelial cross-linking (TCXL) in the treatment of progressive paediatric keratoconus regarding stability, safety and efficacy.

METHODS

This prospective multicentre randomized controlled trial included 97 eyes of 97 paediatric patients with stages I-III ABCD keratoconus grading system, who were randomized into three groups; SCXL group (control group, n = 32; 3 mW/cm2  × 30 min/5.4 J/cm2 ), ACXL (n = 33; 18 mW/cm2  × 5 min/5.4 J/cm2 ) and TCXL (n = 32; 18 mW/cm2  × 5 min/5.4 J/cm2 ). Subjective refraction, uncorrected and corrected visual acuity, keratometry and pachymetry measurements using corneal topography were recorded preoperatively and 1, 2 and 3 years postoperatively.

RESULTS

SCXL group exhibited significant successive improvements in the mean visual, refractive and keratometric parameters throughout the entire postoperative 3 years while ACXL group exhibited significant improvements in visual and keratometric parameters in the first postoperative year that remained stable in second and third postoperative years. TCXL group exhibited significant progressive deterioration in all mean parameters compared to SCXL and ACXL (p < 0.0001). Both SCXL and ACXL revealed final 100% success rate with good stability while TCXL revealed final 22% failure rate with keratoconus progression (p < 0.0001).

CONCLUSION

SCXL and ACXL were comparable in halting keratoconus progression and achieved good stability and safety; however, SCXL was more efficient than ACXL as it yielded greater significant postoperative mean visual, refractive and keratometric improvements achieving smoother corneal remodelling. Both SCXL and ACXL were much superior to TCXL. SCXL is the best CXL treatment option for paediatric keratoconus while ACXL is a good and effective alternative.

Ocular surface squamous neoplasia masquerading as pseudoepitheliomatous hyperplasia in chronic vernal keratoconjunctivitis

We report a rare case of ocular surface squamous neoplasia (OSSN) masquerading as pseudoepitheliomatous hyperplasia in chronic vernal keratoconjunctivitis (VKC). A 24-year-old man presented with a history of bilateral VKC since childhood with a superior limbal mass in the right eye. There was a history of use of intermittent corticosteroids in the past. He underwent impression cytology followed by excision biopsy with wide margins (no touch technique), cryotherapy and amniotic membrane transplantation. Histopathological analysis confirmed the diagnosis of OSSN with mild to moderate dysplasia. This case highlights the importance of strong clinical suspicion and detailed cytological and histopathological examination for early detection and management of OSSN.

Long-Term Clinical Outcome of Tacrolimus Skin Ointment (0.03%) for the Treatment of Vernal Keratoconjunctivitis: A Quasi-Experimental Study

Background Vernal keratoconjunctivitis (VKC) is an allergic conjunctival inflammation with severe ocular complications if left untreated. The current management regimen is plagued with adverse effects, long-term problems, and clinical relapses. Tacrolimus offers an alternative treatment option, and long-term studies are needed to determine its efficacy. Methods A two-year follow-up based study was conducted on moderate to severe VKC patients, who were prescribed tacrolimus skin ointment. The 5-5-5 exacerbation scale was used for the monitoring and grading severity of the disease. Analysis of variance (ANOVA) and intergroup comparisons were conducted on exacerbation scale scores among follow-ups. Results A significant reduction was observed in the total score of severity from baseline (203.17±102.05) to three months' follow-up (69.94±70.54), and it kept reducing for 18 months post therapy. Similar results with statistically significant reduction were observed for all grades of the scale. The relapse rate was 5.71% within a month after therapy cessation, and none of the other patients showed relapse afterward. No significant ocular and systemic complications were observed during the study. Conclusion Tacrolimus is effective in the long-term management of VKC without the complications of conventional steroid-based therapy.

Usability of an Eye Drop Delivery Aid for Single-Dose Instillation: Results from a Market Research Study

Background

One of the challenges of treating chronic ocular diseases like vernal keratoconjunctivitis (VKC), glaucoma, and ocular surface disease is patient adherence to topical medication. To support correct eye drop instillation, a variety of delivery aids have been developed for both single-dose and conventional multi-dose containers.

Methods

To evaluate Dropaid™ Single-dose, an eye drop delivery aid designed for single-dose containers, a usability study was conducted on 30 parents and caregivers of patients with VKC. After assessing the ability to squeeze a single eye drop from the single-dose container onto the eye of a pediatric medical dummy, the delivery aid was evaluated using an 11-point Likert scale on a variety of characteristics: from "very difficult" (-5) to "very easy" (+5).

Results

The majority of participants rated the task of opening the single-dose units (SDUs), preparing, and positioning the Dropaid™ Single-dose device as "very easy". When providing a single eye drop from the container, 87% of participants rated the Dropaid™ Single-dose device as either "very easy" or "easy", with a median rating score of +5.0 (interquartile range [IQR], 4.0-5.0). For general ease of use, 84% considered the delivery aid as either "very easy" or "easy", with a median score of +4.0 (IQR, 3.0-5.0). Most participants (93%) rated Dropaid™ Single-dose as either "very comfortable" or "comfortable" to hold, with a median score of +5.0 (IQR, 4.0-5.0).

Conclusion

The Dropaid™ Single-dose delivery aid demonstrated rapid learning and ease of use across all stages of application, including opening the container, eye drop administration, and handling comfort. Although designed for use with single-dose containers to help eye drop instillation in patients with VKC, Dropaid™ Single-dose may provide a wider utility across a range of other ocular diseases such as glaucoma and dry eye.

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

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

Classification of Subtypes of Vernal Keratoconjunctivitis by Cluster Analysis Based on Clinical Features

Background

Vernal keratoconjunctivitis (VKC) is a refractory ocular allergic disorder that mainly affects boys. A few studies have attempted to develop a classification of subtypes of VKC. In this study, we investigated a computational approach called cluster analysis to separate VKC cases into groups based on clinically relevant characteristics.

Methods

In total, 41 consecutive patients clinically diagnosed with VKC at the Department of Ophthalmology of Fukuoka University Hospital were included. Patients were treated with immunosuppressive eye drops without simultaneous corticosteroid eye drops, except for the occurrence of exacerbations. Collated variables were age at onset, clinical score of ocular lesions at baseline, clinical score of ocular lesions at final visit, clinical score of atopic dermatitis (AD) at baseline, frequency of exacerbations of VKC, serum total IgE level and peripheral blood eosinophil count.

Results

VKC patients were grouped into three clusters by cluster analysis, and cluster 1, 2, and 3 comprised 25, 9 and 7 cases, respectively. There were differences in the incidence of complications of AD and age at onset among the clusters; therefore, we named the three clusters for better understanding as traditional VKC (cluster 1), early-onset atopic keratoconjunctivitis (AKC)/VKC (cluster 2) and puberty-onset AKC (cluster 3).

Conclusion

We found in this study that VKC in childhood has three phenotypes which were previously unknown. Our findings may help to establish precision medicine by focusing on the phenotype of each case to develop individualized medicine to prevent exacerbations.

Prevalence and clinical profile of keratoconus in patients presenting at a provincial hospital in KwaZulu, Natal, South Africa: A case study

Keratoconus (KC) is a progressive, asymmetrical corneal disease, characterized by stromal thinning that leads to distortion, causing vision loss. The visual loss is secondary to corneal scarring, irregular astigmatism, and myopia. The prevalence of KC has been reported to differ in different parts of the world. The study aimed to determine the prevalence and profile of patients with KC presenting to a provincial hospital in KwaZulu-Natal, South Africa. A retrospective study design was used to review 412 clinical records of patients attending the McCord Provincial Eye Hospital (MPEH) during a five-year period (2016-2020). Data on age, race, refraction, clinical profile, treatment plan, and diagnosis were ascertained. The prevalence of KC in MPEH was found to be 13.7% with a mean age of 24.7±7.94 years. Black African and females had a higher frequency of KC compared to males and other ethnic groups. Most of the patients presented with a severe stage of KC and referral was the most common management. Central corneal thinning and Munson's sign were the most prevalent clinical signs. There was no statistically significant difference between the worse and better eye when comparing the clinical signs. The prevalence and clinical profile of patients with KC in this study was similar to that reported by previous studies and more in Blacks and females. Population based epidemiological studies are needed to determine the prevalence of KC in South Africa to enable early clinical interventions.

Dendritic Cell Density and Morphology Can Be Used to Differentiate Vernal Keratoconjunctivitis from Allergic Conjunctivitis

The aim of the study was to compare the distribution of corneal and conjunctival epithelial dendritic cells (DCs) in vernal keratoconjunctivitis (VKC), allergic conjunctivitis (AC), and non-allergic controls to examine if the allergy type causes differences in immune cell activation. The prospective study included 60 participants: 20 with VKC, 20 with AC, and 20 non-allergic controls. In vivo confocal microscopy was performed on the right eye. The locations scanned included the corneal centre, inferior whorl, corneal periphery, corneal limbus, and bulbar conjunctiva. The DCs were counted manually, and their morphology was assessed for the largest cell body size, the presence of dendrites, and the presence of long and thick dendrites. The DC density was higher in VKC and AC compared to non-allergic group at all locations (p ≤ 0.01) except at the inferior whorl. The DC density in VKC participants was significantly higher than in AC at the limbus (p < 0.001) but not at other locations. Both the AC and the VKC group had larger DC bodies at the corneal periphery and limbus compared to the non-allergic group (p ≤ 0.03). The study found a higher proportion of participants with DCs exhibiting long dendrites at both the corneal periphery in AC (p = 0.01) and at the corneal centre, periphery, and limbus in VKC, compared to the non-allergic group (p ≤ 0.001). In conclusion, a higher DC density at the limbus may be a marker of more severe VKC. DCs with larger cell bodies and a greater proportion of participants with DCs displaying long dendrites can be potential markers to differentiate allergy from non-allergy, and more severe forms of allergy from milder forms.

Impact of Exposomes on Ocular Surface Diseases

Ocular surface diseases (OSDs) are significant causes of ocular morbidity, and are often associated with chronic inflammation, redness, irritation, discomfort, and pain. In severe OSDs, loss of vision can result from ocular surface failure, characterised by limbal stem cell deficiencies, corneal vascularisation, corneal opacification, and surface keratinisation. External and internal exposomes are measures of environmental factors that individuals are exposed to, and have been increasingly studied for their impact on ocular surface diseases. External exposomes consist of external environmental factors such as dust, pollution, and stress; internal exposomes consist of the surface microbiome, gut microflora, and oxidative stress. Concerning internal exposomes, alterations in the commensal ocular surface microbiome of patients with OSDs are increasingly reported due to advancements in metagenomics using next-generation sequencing. Changes in the microbiome may be a consequence of the underlying disease processes or may have a role in the pathogenesis of OSDs. Understanding the changes in the ocular surface microbiome and the impact of various other exposomes may also help to establish the causative factors underlying ocular surface inflammation and scarring, the hallmarks of OSDs. This review provides a summary of the current evidence on exposomes in various OSDs.

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.

Assessment of the efficacy of olopatadine 0.1% in the treatment of vernal keratoconjunctivitis in terms of clinical improvement based on total ocular symptom score and ocular surface disease index

Purpose

The main objective of this study is to explore the efficacy of olopatadine 0.1% treatment in the resolution of symptoms of vernal keratoconjunctivitis (VKC) among the Indian population.

Methods

This single-center, prospective cohort study involved 234 patients with VKC. Patients were treated with olopatadine 0.1%, twice daily for a period of 12 weeks and then followed up in 1^st week, 4^th week, 3^rd month, and 6^th month. The extent of relief in the symptoms of VKC was measured using total ocular symptom score (TOSS) and ocular surface disease index (OSDI).

Results

In the present study, the dropout rate was 5.6%. Total of 136 males and 85 females with a mean age of 37.68 ± 11.35 years completed the study. TOSS score reduced from 58.85 to 5.06 and the OSDI score reduced from 75.41 to 11.2 with statistical significance (P < 0.01) from 1^st week to 6^th week after olopatadine 0.1% treatment. The data showed relief in subjective symptoms of itching, tearing, and redness, and relief in discomfort in functions related to ocular grittiness, visuals like reading, and environmental like tolerability in dry conditions. Further, olopatadine 0.1% was effective in both males and females, and patients across ages 18-70 years.

Conclusion

Based on TOSS and OSDI scores, the findings of this study validate safety and tolerability as revealed by low adverse effects and moderate efficacy of olopatadine 0.1% in reducing VKC symptoms in a broader age group (18-70 years) of both genders.

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.

Association between keratoconus and allergic conjunctivitis in children attending a Tertiary Hospital in Nigeria

Objective: To ascertain an association between keratoconus and allergic conjunctivitis and to know if it is necessary to investigate all patients with allergic conjunctivitis for keratoconus. Methods: A hospital-based prospective study in which the eyes of children presenting with ocular allergic diseases were examined. Social demographics and clinical data were captured in a questionnaire. All the patients underwent keratometry using the autorefractor-keratometer and the pachymeter was used to measure the central corneal thickness. Data analysis was done with IBM SPSS version 28 for Windows. Frequency and chi-square were used as descriptive statistics to determine the association between dependent and independent variables. Inferential statistics using one-way ANOVA and t-test. P - Value at <0.05 was considered statistically significant. Results: 121 children with allergic conjunctivitis were reviewed. Males were 72 and females 49. The visual acuity was 6/ 6-6/ 18 in 116, and mild visual impairment - 6/ 18-6/ 60 in 5. The most common complaint was frequent itching in 109 (90.1%). Keratometry was normal in 120 (99.5%), while probable keratoconus was found by keratometry in only one patient (0.5%). Central corneal thickness was within the normal range in 33 (27.3%) children, 43 (35.5%) had thin corneas, while 45 (37.2%) had cornea thickness of more than 560 microns. Discussion: Pediatric keratoconus tends to be more aggressive than adult keratoconus with an increased risk of corneal opacities and subsequent keratoplasty. As a result of these negative impacts, early detection and prompt treatment are mandatory. Conclusion: The prevalence of keratoconus was not found to be high in this study population, but with facts emerging between the association of allergic conjunctivitis, and increased prevalence of keratoconus, it is pertinent to integrate keratoconus screening as part of the management of allergic conjunctivitis using an appropriate tool such as video keratography and slit lamp biomicroscope. Abbreviations: KC = Keratoconus, CLEK = Collaborative Longitudinal Evaluation of Keratoconus, SAC = Seasonal Allergic Conjunctivitis, PAC = Perennial Allergic Conjunctivitis, VKC = Vernal Keratoconjunctivitis, IOP = Intraocular Pressure, CCT = Central Corneal Thickness, TNF-α = Tumor Necrosis Factor-Alpha, IL = Interleukin.

Prevalence of dry eye disease in the patients of allergic conjunctivitis: Hospital-based cross-sectional study

PURPOSE

Allergic conjunctivitis (AC) is commonly associated with dry eye. This study was conducted to assess the prevalence of dry eye in different subsets of AC patients.

METHODS

This observational, cross-sectional study, conducted in the Department of Ophthalmology of a tertiary center in north India, included 132 patients of AC. The diagnosis of dry eye disease (DED) was made on the basis of Ocular Surface Disease Index (OSDI), Schirmer's test, and tear film break-up time (TFBUT).

RESULTS

The prevalence of dry eye in AC patients was found to range between 31% and 36%. On OSDI scoring, 20.45% of patients had mild, 18.18% moderate, and 31.81% had a severe grade of DED, respectively. The mean OSDI score was noted to be significantly higher in patients with perennial allergic conjunctivitis (PAC) (29.82 ± 12.41), followed by seasonal allergic conjunctivitis (SAC) (25.35 ± 12.88), and least in the patients of vernal keratoconjunctivitis (VKC) (13.60 ± 8.63) (p < 0.0001), respectively. The TFBUT was found to be less than 10 s in 45.45% of PAC, 30.43% of SAC, and 20% of VKC patients, respectively. The difference between the mean TFBUT among the three groups was statistically insignificant (p = 0.683). Schirmer's test value of <10 mm was observed in 45.45% of PAC, 43.47% of SAC, and 10% of VKC patients, respectively.

CONCLUSION

This study revealed a high prevalence of DED in patients with AC. Among the different types of AC patients, PAC had the highest percentage of DED followed by SAC and least in VKC, respectively.

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.

Clinical Study on Corneal Topographical Changes in Vernal Keratoconjunctivitis by Using OCULUS Pentacam®

PURPOSE

To evaluate the corneal topographical changes in vernal keratoconjunctivitis (VKC) subjects using OCULUS Pentacam.

DESIGN

This was a cross-sectional study.

METHODS

VKC patients and normal subjects who fulfilled the inclusion and exclusion criteria were recruited by convenience sampling into the study. Subjects underwent a best-corrected visual acuity measurement with a Snellen chart, retinoscopy, and corneal topography (OCULUS Pentacam®), followed by anterior segment and fundus examination and intraocular pressure measurement. Data were collected and analyzed using SPSS version 26.0 for Windows (SPSS Inc. Chicago, IL, USA). A p-value <0.05 was considered statistically significant.

RESULTS

A total of 78 eyes of 43 VKC patients and 84 eyes of normal subjects were included in the study. Most of the VKC subjects were Malay males aged 10 years or less. A majority (71.8%) had palpebral VKC of five years duration or less (57.7%) and presented between the ages of six and 10 years (44.9%). Central corneal curvature and astigmatism were significantly higher in VKC subjects compared to the normal population (p < 0.05). The minimal pachymetry was significantly lower with a longer duration of VKC (p < 0.05). Older age of presentation of VKC was associated with higher central corneal curvatures and thinner minimal pachymetry (p < 0.05). There was no association between the type of VKC and corneal topography changes. The prevalence of keratoconus and subclinical keratoconus among VKC subjects was 10.3% and 11.5%, respectively.

CONCLUSION

Longer duration and older age of presentation of VKC are associated with significant corneal topographical changes, thus exposing them to a higher risk of the future development of keratoconus.

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.

Practice patterns and opinions in the treatment of allergic eye disease: A survey among Indian ophthalmologists

Purpose

Management of allergic eye disease is seldom straightforward and often challenging. We conducted an online survey to elicit opinions on the preferred practice pattern in the treatment of allergic eye disease.

Methods

An online survey questionnaire was sent to all practicing ophthalmologists using social media platforms. The respondents were asked about their clinical experience and preferred treatment in various scenarios such as mild-moderate vernal keratoconjunctivitis (VKC), chronic VKC, refractory VKC, steroid responders, giant papillae, and shield ulcer. Respondents were asked about the newer molecule (alcaftadine) and reservations regarding systemic immuno-suppressants and ordering allergy tests in their practice.

Results

Ninety - one participants responded to the survey. About 57.1% of ophthalmologists reported coming across more than 10 cases per week in their practice. The most common age group was 5-10 years (61.1%), but adult onset VKC was also reported at 41.6% (1-2 per month), 37.1% (3-5 per month), and 13.5% (more than 10 per month). The disease is perennially present (36.7%), and a mixed form has been reported by 47.8% of ophthalmologists. Dual-acting agents were preferred by 40% in mild-moderate clinical variants. Topical steroids in slow tapering dosage were preferred by 86.7% in their prescription. Tacrolimus 0.03% was preferred by 65.9% and given for at least 3 months of continuous usage by 47.6% of ophthalmologists. High-dose topical steroids were preferred for giant papillae (67.8%) and Shields ulcers (68.3%) in our survey. Supratarsal steroid injection was preferred by 50% in treating refractory VKC in our survey.

Conclusion

Allergic eye disease is a common yet annoying disease. The signs and symptoms can vary from subtle, innocuous forms to devastating variants affecting vision and day-to-day work. This survey aims to elicit responses from clinicians spreading across different geographical areas and compares responses based on experience in practice.

Role of Oncostatin M in the Pathogenesis of Vernal Keratoconjunctivitis: Focus on the Barrier Function of the Epithelium and Interleukin-33 Production by Fibroblasts

Purpose

Vernal keratoconjunctivitis (VKC) is a severe, recurrent allergic conjunctivitis. Previously, we found high concentrations of oncostatin M (OSM) in the tears of patients with VKC. Here, we investigated the role of OSM in VKC by focusing on epithelial barrier function and IL-33 production.

Methods

To assess the effect of OSM on the barrier function of human conjunctival epithelial cells (HConEpiCs), we measured transepithelial electrical resistance and dextran permeability. We also assessed expression of tight junction-related proteins such as E-cadherin and ZO-1 in HConEpiCs by Western blotting and immunofluorescence. Then we used immunohistochemistry to evaluate expression of Ki-67, E-cadherin, epithelial-mesenchymal transition-related proteins, and IL-33 in giant papillae (GPs) from patients with VKC. In addition, we used Western blotting, microarray, quantitative real-time polymerase chain reaction, and enzyme-linked immunosorbent assay to examine whether OSM activates signal transducer and activator of transcription 1 (STAT1) or STAT3 and induces the expression of various genes in human conjunctival fibroblasts (HConFs).

Results

OSM reduced expression of E-cadherin and ZO-1 in HConEpiCs, indicating barrier dysfunction. In immunohistochemistry, Ki-67 expression was present in the lower epithelial layer of the GPs, and E-cadherin expression was reduced in the superficial and lower layers; double staining revealed that GPs had a high number of fibroblasts expressing IL-33. In addition, in HConFs, OSM phosphorylated both STAT1 and STAT3 and induced IL-33.

Conclusions

OSM has important roles in severe, prolonged allergic inflammation by inducing epithelial barrier dysfunction and IL-33 production by conjunctival fibroblasts.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Safety and efficacy of topical tacrolimus 0.03% in the management of vernal keratoconjunctivitis: a non-randomized controlled clinical trial

Background

Vernal keratoconjunctivitis (VKC) is a bilateral, recurrent, chronic conjunctival inflammatory disease with seasonal exacerbations. This study aimed to assess the efficacy and safety of tacrolimus 0.03% eye ointment in the management of chronic VKC.

Methods

This was an open-label, prospective, non-randomized, comparative interventional study that enrolled 50 patients with chronic VKC, who were allocated to one of two groups. The first group was treated with tacrolimus 0.03% eye ointment twice daily for 2 months then once daily for 2 months, followed by once every other day for another 2 months. The control group was treated with standard anti-allergic drugs, topical fluorometholone 0.1% eye drops three times daily for 2 weeks and gradually tapered for another 2 weeks, with topical olopatadine 0.1% administered twice daily during the follow-up period. Disease severity was assessed using a four-point scale for symptoms and signs. Treatment efficacy was assessed by analyzing changes in symptoms and signs, and by clinical photography.

Results

Fifty patients with bilateral chronic VKC completed the follow-up. The mean (standard deviation) ages of the tacrolimus and control groups were comparable (16.20 [5.10] years versus 16.48 [4.19] years, P > 0.05). The most commonly reported symptom was itching, and the most common signs were papillary hypertrophy and conjunctival hyperemia. All symptoms and signs were significantly reduced after treatment in both groups. The tacrolimus group showed a more significant improvement at 3 and 6 months in the mean composite symptom score (both P < 0.05) and in the mean composite sign score (both P < 0.05). Regarding complications, one case of increased intraocular pressure occurred in the control group (4%) after 2 weeks of steroid treatment, while there were no complications in the tacrolimus group, except for some reports of stinging sensation, which was well tolerated.

Conclusions

Treatment of chronic bilateral VKC with tacrolimus 0.03% eye ointment is effective and safe. It could be considered an alternative treatment to reduce steroid-associated complications in patients with chronic VKC. Future double-blinded clinical trials with a longer follow-up period are necessary to confirm our findings and to determine the long-term safety of topical tacrolimus 0.03% ointment in VKC.

Lirentelimab for severe and chronic forms of allergic conjunctivitis

BACKGROUND

Allergic conjunctivitis (AC) is an ocular inflammatory disease with symptoms driven by eosinophils and mast cells. Allergic comorbidities are common. Current treatments are often ineffective in severe AC and limited by potential side effects. Lirentelimab is an anti-sialic acid-binding immunoglobulin-like lectin-8 mAb that depletes eosinophils and inhibits mast cells.

OBJECTIVE

We sought to determine safety and preliminary efficacy of lirentelimab in an open-label, phase 1b study.

METHODS

Patients with chronic, severely symptomatic atopic keratoconjunctivitis, vernal keratoconjunctivitis, and perennial AC, and who had history of topical or systemic corticosteroid use, were enrolled to receive up to 6 monthly lirentelimab infusions (dose 1: 0.3 mg/kg, dose 2: 1 mg/kg, subsequent doses: 1 or 3 mg/kg). Changes from baseline in peripheral blood eosinophils, changes in patient-reported symptoms (measured by daily Allergic Conjunctivitis Symptom Questionnaire, including atopic comorbidities), changes in investigator-reported ocular signs and symptoms (Ocular Symptom Scores), changes in quality of life, and changes in tear cytokine and chemokine levels were assessed.

RESULTS

Thirty patients were enrolled (atopic keratoconjunctivitis n = 13, vernal keratoconjunctivitis n = 1, perennial AC n = 16), 87% of whom had atopic comorbidities. After lirentelimab treatment, mean improvement was observed in Allergic Conjunctivitis Symptom Questionnaire score (-61%; 95% CI, -75% to -48%) and Ocular Symptom Scores (-53%; 95% CI, -76% to -31%), consistent across atopic keratoconjunctivitis, vernal keratoconjunctivitis, and perennial AC groups. There was substantial improvement in atopic comorbidities, with -55% (95% CI, -78% to -31%), -50% (95% CI, -82% to -19%), and -63% (95% CI, -87% and -38%) reduction in symptoms of atopic dermatitis, asthma, and rhinitis, respectively. Levels of key mediators of inflammation were reduced in patient tears after lirentelimab treatment. The most common adverse effects were mild to moderate infusion-related reactions.

CONCLUSIONS

Lirentelimab was well tolerated, improved severe AC and concomitant atopic symptoms, and reduced inflammatory mediators in patient tears.

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

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

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

Purpose:

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

Methods:

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

Results:

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

Conclusion:

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

Epithelial barrier dysfunction in ocular allergy

The epithelial barrier is the first line of defense that forms a protective barrier against pathogens, pollutants, and allergens. Epithelial barrier dysfunction has been recently implicated in the development of allergic diseases such as asthma, atopic dermatitis, food allergy, and rhinitis. However, there is limited knowledge on epithelial barrier dysfunction in ocular allergy (OA). Since the ocular surface is directly exposed to the environment, it is important to understand the role of ocular epithelia and their dysfunction in OA. Impaired epithelial barrier enhances allergen uptake, which lead to activation of immune responses and development of chronic inflammation as seen in allergies. Abnormal expression of tight junction proteins that helps to maintain epithelial integrity has been reported in OA but sufficient data not available in chronic atopic (AKC) and vernal keratoconjunctivitis (VKC), the pathophysiology of which is not just complex, but also the current treatments are not completely effective. This review provides an overview of studies, which indicates the role of barrier dysfunction in OA, and highlights how ocular barrier dysfunction possibly contributes to the disease pathogenesis. The review also explores the potential of ocular epithelial barrier repair strategies as preventive and therapeutic approach.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Occurrence of vernal keratoconjunctivitis in children infected with human immunodeficiency virus

Purpose:

To study the occurrence of vernal keratoconjunctivitis (VKC) as an ocular manifestation of human immunodeficiency virus (HIV) in pediatric patients.

Methods:

A retrospective study was done on the observations of cases of HIV-positive children. All seropositive patients from the Anti-Retroviral Therapy clinic were referred to the department of ophthalmology for evaluation. Retrospective correlation of CD4 count with active cases of VKC was done. All patients underwent a comprehensive ophthalmic evaluation including visual acuity, slit lamp and dilated fundus examination.

Results:

A total of 72 children were included, 70 males and 2 females. Of these, 63 (87.5%) had VKC, three (4.2%) had cataract, two (2.8%) had cytomegalovirus retinitis retinitis, and four (5.5%) had no ophthalmic findings.

Conclusion:

There is a an evident association of HIV, VKC cases, and reduced CD4 count. More research is required on this topic.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Comparison of posterior corneal elevation in children with and without vernal keratoconjunctivitis using a new tomographer

Purpose:

To assess the posterior corneal elevation (PCE) in children with vernal keratoconjunctivitis (VKC) and compare the same with that of age and gender-matched normal children.

Methods:

This was a case control study. We included 110 children attending the Pediatric ophthalmology outpatient department of a tertiary eye care center in South India between September 2019 and June 2020. Fifty-five children with VKC and 55 normal age and gender-matched children were examined by Sirius tomographer/topographer (CSO, Italy) to determine the PCE, thinnest corneal thickness (TCT), simulated K (Sim K), keratoconus front (KVf) and keratoconus vertex back (KVb). The parameters were compared between the two groups.

Results:

A total of 220 eyes of 110 children were examined. The mean age in both groups was 10.44 ± 3.28 years, each group included 44 males and 11 females. There was no statistically significant difference in TCT and Sim K between the two groups. The mean PCE was 18.8 ± 8.4 μm in VKC group and 11.7 ± 3.9 μm in control group (P < 0.001). Both KVf and KVb were significantly higher in VKC group when compared to the control group.

Conclusion:

Children with VKC have significantly higher PCE as measured by Sirius tomographer, and hence, all VKC children should be screened for development of KC and the Sirius tomographer may be an appropriate tool for the same.

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.

Comparison of penetrating keratoplasty and deep anterior lamellar keratoplasty in keratoconus eyes with vernal keratoconjunctivitis

Purpose:

The purpose of the study is to compare outcomes after penetrating keratoplasty (PK) against deep anterior lamellar keratoplasty (DALK) for keratoconus in patients with vernal keratoconjunctivitis (VKC).

Methods:

Keratoconic patients with VKC who received PK (n = 55, group 1) or DALK (n = 62, group 2) were retrospectively enrolled. The Student’s t test, Mann–Whitney test, Fisher’s exact test, chi-square test, and Kaplan–Meier survival curve were used to compare outcomes between the groups.

Results:

The follow-up period was 59.4 ± 44.1 and 62.4 ± 38.9 months in groups 1 and 2, respectively (p = 0.70). Postoperative best spectacle-corrected visual acuity was 0.24 ± 0.18 and 0.29 ± 0.19 logMAR, respectively (p = 0.13). Graft rejection occurred in 34.6% and 25.8% of eyes in groups 1 and 2, respectively (p = 0.30). Groups 1 and 2 were comparable in the rates of cataract (3.6% and 12.9%, respectively, p = 0.07) and high intraocular pressure (3.6% and 8.1%, respectively, p = 0.31). Compared with the eyes with inactive VKC, PK eyes that experienced postoperative disease reactivation had a higher rate of suture abscesses (10.9% versus 50.0%, respectively, p = 0.01) and suture-tract vascularization (6.5% versus 33.3%, respectively, p = 0.03). Similarly, disease reactivation significantly increased suture abscesses from 27.3% to 51.7% (p = 0.03) and suture-tract vascularization from 18.2% to 49.6% (p = 0.005) in the DALK group. The graft survival rates were 95.3% in group 1 and 87.9% in group 2 at the 4-year follow-up, with mean durations of 14.4 and 11.1 months, respectively (p = 0.20).

Conclusion:

The results indicate no difference in outcomes between PK and DALK for keratoconus in patients with VKC. Postoperative VKC reactivation increased the rate of suture-related problems after both techniques of keratoplasty.

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.

To evaluate the efficacy and safety of olopatadine 0.1% ophthalmic solution and bepotastine 1.5% ophthalmic solution in patients with vernal keratoconjunctivitis in a tertiary care hospital

INTRODUCTION

Vernal conjunctivitis comprises 0.5% of allergic eye diseases. The study is intended to collate the effectiveness of drugs by observing the reduction in signs and symptoms.

OBJECTIVES

The objective of the study is to evaluate the effectiveness and safety of olopatadine 0.1% ophthalmic drops with bepotastine besilate 1.5% ophthalmic drops in patients with vernal keratoconjunctivitis (VKC).

MATERIALS AND METHODS

A randomized, open-label, comparative study conducted in Sarojini Devi Eye Hospital, Telangana. The study included 50 patients diagnosed with VKC, of which Group A and Group B were given olopatadine 0.1% ophthalmic drops and bepotastine besilate 1.5% ophthalmic drops, respectively, twice a day for 8 weeks. The reduction in signs and symptoms in both groups was compared. The observations and results were tabulated accordingly, and data were analyzed using the SPSS. The unpaired t-test is used as the test of significance in between two groups. P value is statistically significant when it is less than 0.05.

RESULTS

Overall, 50 cases were included in the study, 72% of total patients were in the age group of 5-10 years, and 28% were in the age group of 11-15 years. There were 39 males and 11 females. After 8 weeks of follow-up, the mean reduction in the scoring of symptoms and signs provided better and quicker relief of watering, ocular discomfort, and conjunctival hyperemia with bepotastine 1.5% eye drops. Olopatadine 0.1% eye drops provided faster improvement in papillary hypertrophy. Both drugs were equally effective in reducing itching. Laboratory findings of absolute eosinophil count had no statistical significance in between the two groups.

CONCLUSIONS

In this study, based on the evaluation of therapeutic performance, bepotastine eye drops proved quicker relief of symptoms and signs compared to olopatadine eye drops but was not statistically significant which would prove beneficial for the patients.

Current Knowledge in Allergic Conjunctivitis

Allergic conjunctivitis is a disease of increasing prevalence that affects both children and adults and causes significant deterioration of their quality of life and sometimes irreversible visual damage. There are various forms of the disease, some are allergen-induced such as seasonal and perennial allergic conjunctivitis, giant papillary conjunctivitis, and contact allergic blepharoconjunctivitis, whereas others are not always explained by allergen exposure, such as vernal keratoconjunctivitis and atopic keratoconjunctivitis. We review their clinical course, characteristics, and differential diagnosis, and highlight recent advances in their pathophysiology and treatment.

Pediatric keratoconus - Current perspectives and clinical challenges

Keratoconus is an ectatic corneal disease characterized by progressive stromal thinning, irregular astigmatism, and defective vision. It can be unilateral or bilateral with asymmetric presentation. It starts at puberty and either progresses rapidly to an advanced stage of the disease or stops in case of delayed onset and slow progression. Pediatric keratoconus is more aggressive than in adults and the management protocols differ because of various rationales such as accelerated progression, advanced stage of disease at the time of diagnosis and co-morbidities. It poses a burden to the society as it affects the quality of life, social, and educational development in children. Hence early diagnosis, recognition of progression, and timely intervention with collagen crosslinking is imperative to arrest the worsening. Association with systemic syndromes and ocular comorbidities can be of concern in pediatric keratoconus. Severe ocular allergy when associated hastens progress and complicates timely intervention of crosslinking treatment and compliance to contact lens wear. Keratoplasty in pediatric keratoconus has good outcomes but can encounter frequent suture-related concerns. This article discusses the epidemiology, etiopathogenesis, clinical challenges, and current perspectives of management of pediatric keratoconus.

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.

Rosai-Dorfman disease: Isolated epibulbar mass in patient with vernal keratoconjunctivitis

A 29-year-old male known case of vernal keratoconjunctivitis (VKC) presented with 5-month history of a rapidly growing mass on the temporal aspect of the right cornea. The 9 × 9 mm epibulbar lesion was excised and histologically showed features of extranodal Rosai Dorfman disease (RDD) with emperipolesis of eosinophils. The lesion did not recur following excision. The association of RDD with VKC has not been previously reported; however, the causal relationship remains unclear.

Prevalence of refractive error and visual impairment among school-age children of Hargesia, Somaliland, Somalia

Background

Childhood visual impairment is a global public health problem, especially in low and middle-income countries. Its most common causes are avoidable by early diagnosis and treatment.

Aims

To assess prevalence of refractive error and visual impairment among school-aged children in Hargeisa, Somaliland, Somalia.

Methods

This was a cross-sectional study of 1204 students (aged 6-15 years) in 8 randomly selected primary schools in Hargeisa from November 2017 to January 2018. We used the modified Refractive Error Study in Children to determine prevalence of refractive error and visual impairment, including the following investigations: distance visual acuity, assessed by Snellen Tumbling E-chart; refraction, assessed by retinoscope binocular vision assessment; and examination of anterior and posterior segments.

Results

Prevalence of uncorrected, presenting and best-corrected visual impairment of 6/12 or worse was 13.6%, 7.6% and 0.75%, respectively. Only 16 of 91 (17.6%) children were using spectacles and the rest were unaware of the problem. Refractive error was the cause of visual impairment in 76.8% of participants, amblyopia in 22.0%, trachoma in 2.4%, and corneal opacity and cataract in 0.6%. Anterior segment abnormalities were found in 8.3%, mainly vernal keratoconjunctivitis, while posterior abnormalities were observed in 0.7%. Prevalence of myopia was 9.1%, hypermetropia 2.7% and astigmatism 3.9%. Prevalence of visual impairment because of Refractive Error was associated with increasing age, but there was no significant association with school grade or sex.

Conclusion

Prevalence of visual impairment among school-aged children in Hargeisa was high, and the leading cause was uncorrected Refractive Error. There are barriers to care and it is critical that they are overcome.

Is oxidative stress involved in vernal keratoconjunctivitis? Results from a pilot study in children

BACKGROUND

Vernal keratoconjunctivitis (VKC) is a rare chronic conjunctivitis characterized by a predominantly eosinophil-mediated inflammatory disorder that could develop critical complications such as blindness. Oxidative stress plays a pivotal role in the pathogenesis of several allergic diseases. The role of oxidative stress has been hypothesized in VKC, but no study explored this issue. Furthermore, cyclosporine A (CsA) exerts an anti-inflammatory and antioxidant action on the conjunctiva. This study aimed to assess the oxidative stress in VKC patients and controls and to study the effect of CsA on oxidative stress in these subjects.

METHODS

Thirty-six consecutive children, including 12 VKC (nine males, 75%; mean age 10.17; SD ± 2.48) patients without treatment, 12 VKC patients treated with CsA (nine males, 75%; mean age 9.08; SD ± 2.75), and 12 controls (CT) (seven males, 58%; mean age 8.58; SD ± 1.78), were recruited. A cross-sectional study was performed to compare H₂ O₂ in the serum with that in the tears of these children.

RESULTS

Compared with CT and VKC children treated with CsA, VKC untreated children had significantly higher values of hydrogen peroxide (H₂ O₂ ) in the serum and the tears. No significant differences were observed between CT and VKC treated with CsA. A significant correlation was found at the linear regression analysis between serum and tear H₂ O₂ levels.

CONCLUSION

This study provides the first report attesting that patients with VKC have high oxidative stress; furthermore, it suggests that CsA could have an anti-inflammatory and antioxidant action that could be useful to prevent the poor VKC outcome.