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Vernal keratoconjunctivitis

AI overview

Vernal keratoconjunctivitis is a recurrent, bilateral, and self-limiting type of conjunctivitis (pink eye) having a periodic seasonal incidence.

Key points
  • VKC is thought to be an allergic disorder involving IgE mediated mechanisms.
    source quote
    VKC is thought to be an allergic disorder in which IgE mediated mechanism play a role.
  • Patients often have a family history of other atopic diseases such as hay fever, asthma or eczema.
    source quote
    Such patients often give family history of other atopic diseases such as hay fever , asthma or eczema
  • It predominantly affects individuals aged 4–20 years and is more common in boys than girls.
    source quote
    Age and sex – 4–20 years; more common in boys than girls.
  • It is more common in summer and more prevalent in the tropics.
    source quote
    More common in summer. Hence, the name Spring catarrh is a misnomer.
  • Corneal involvement may be primary or secondary due to extension of limbal lesions.
    source quote
    Corneal involvement in VKC may be primary or secondary due to extension of limbal lesions.
Symptoms
  • Characterised by marked burning and itchy sensations which may be intolerable.
    source quote
    VKC is characterised by marked burning and itchy sensations which may be intolerable and accentuates when patient comes in a warm humid atmosphere.
  • Symptoms accentuate in warm humid atmosphere.
    source quote
    accentuates when patient comes in a warm humid atmosphere
  • Associated symptoms include mild photophobia, lacrimation, stringy discharge and heaviness of eyelids.
    source quote
    Associated symptoms include mild photophobia in case of corneal involvement, lacrimation , stringy discharge and heaviness of eyelids.
Diagnosis
  • VKC is classified into three clinical forms per Cameron Classification: palpebral, bulbar, and mixed.
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    Signs of VKC can be described in three clinical forms (Cameron Classification):
  • Palpebral form involves upper tarsal conjunctiva with cobblestone or pavement stone arrangement of papillae.
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    Typical lesion is characterized by the presence of hard, flat-topped papillae arranged in cobblestone or pavement stone fashion.
  • Bulbar form shows dusky red triangular congestion, gelatinous thickened tissue around limbus, and Tranta's spots.
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    It is characterised by dusky red triangular congestion of bulbar conjunctiva in palpebral area, gelatinous thickened accumulation of tissue around limbus and presence of discrete whitish raised dots along the limbus (Tranta's spots).
  • VKC is classified into clinical grades 0 to 3 based on severity.
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    Based on severity, authors have classified VKC into clinical grades:
  • Grade 3 severe cases involve symptoms, photophobia, and SPK's or corneal ulcer.
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    Grade 3 SEVERE - Symptoms, photophobia, mild to moderate SPK's OR with Diffuse SPK or corneal ulcer
Treatment
  • Topical steroids are effective; commonly used solutions include fluorometholone, medrysone, betamethasone or dexamethasone.
    source quote
    Topical steroids are effective. Commonly used solutions are of fluorometholone , medrysone , betamethasone or dexamethasone .
  • Mast cell stabilizers such as sodium cromoglycate (2%) drops are effective, especially for atopic cases.
    source quote
    Mast cell stabilizers such as sodium cromoglycate (2%) drops 4–5 times a day are quite effective in controlling VKC, especially atopic ones.
  • Topical Cyclosporine is reserved for unresponsive cases.
    source quote
    Topical Cyclosporine is reserved for unresponsive cases.
  • Acetyl cysteine (0.5%) used topically has mucolytic properties useful in early plaque formation.
    source quote
    Acetyl cysteine (0.5%) used topically has mucolytic properties and is useful in the treatment of early plaque formation.
  • Systemic therapy includes oral antihistamines and oral steroids for severe cases.
    source quote
    Oral antihistamines and oral steroids for severe cases.
  • Large papillae may be treated with cryo application, surgical excision, or supratarsal application of long-acting steroids.
    source quote
    Treatment of large papillae – Cryo application, surgical excision or supratarsal application of long-acting steroids.
  • General measures include dark goggles, cold compresses, ice packs, and change of place from hot to cold areas.
    source quote
    General measures include use of dark goggles to prevent photophobia, cold compresses and ice pack for soothing effects, change of place from hot to cold areas.
  • Ulcerative vernal keratitis may require debridement, superficial keratectomy, excimer laser therapeutic keratectomy, or amniotic membrane transplantation.
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    Ulcerative vernal keratitis require surgical treatment in the form of debridement, superficial keratectomy , excimer laser therapeutic keratectomy, as well as amniotic membrane transplantation to enhance re-epithelialisation.
  • Tacrolimus ointment (0.1%) used topically twice daily is showing encouraging results.
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    Recently treatment with tacrolimus ointment (0.1%) used topically twice daily is showing encouraging results.
Red flags
  • Severe cases may involve corneal ulceration (shield ulceration).
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    Ulcerative vernal keratitis (shield ulceration).
  • In severe cases papillae undergo hypertrophy to produce giant papillae.
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    In severe cases papillae undergo hypertrophy to produce cauliflower-like excrescences of 'giant papillae'.
  • Vernal keratopathy includes punctuate epithelial keratitis, ulcerative vernal keratitis, vernal corneal plaques, subepithelial scarring, and pseudogerontoxon.
    source quote
    Vernal keratopathy includes 5 types of lesions.
Prognosis

Self-limiting, recurrent, bilateral condition with periodic seasonal incidence.

AI-synthesized from the Wikipedia article “Vernal keratoconjunctivitis”. Not medical advice. Verify source →
Vernal keratoconjunctivitis
Other namesSpring catarrh; Vernal catarrh; Warm weather conjunctivitis
Some of the cornea and conjunctiva findings in vernal conjunctivitis
SpecialtyOphthalmology

Vernal keratoconjunctivitis (VKC, also Spring catarrh, Vernal catarrh or Warm weather conjunctivitis) is a recurrent, bilateral, and self-limiting type of conjunctivitis (pink eye) having a periodic seasonal incidence.

Corneal involvement in VKC may be primary or secondary due to extension of limbal lesions. Vernal keratopathy includes 5 types of lesions.[citation needed]

  1. Punctuate epithelial keratitis.
  2. Ulcerative vernal keratitis (shield ulceration).
  3. Vernal corneal plaques.
  4. Subepithelial scarring.
  5. Pseudogerontoxon.

  • Symptoms – VKC is characterised by marked burning and itchy sensations which may be intolerable and accentuates when patient comes in a warm humid atmosphere. Associated symptoms include mild photophobia in case of corneal involvement, lacrimation, stringy discharge and heaviness of eyelids.[1]
  • Signs of VKC can be described in three clinical forms (Cameron Classification):[2]
  1. Palpebral form – Usually upper tarsal conjunctiva of both the eyes is involved. Typical lesion is characterized by the presence of hard, flat-topped papillae arranged in cobblestone or pavement stone fashion. In severe cases papillae undergo hypertrophy to produce cauliflower-like excrescences of 'giant papillae'.
  2. Bulbar form – It is characterised by dusky red triangular congestion of bulbar conjunctiva in palpebral area, gelatinous thickened accumulation of tissue around limbus and presence of discrete whitish raised dots along the limbus (Tranta's spots).
  3. Mixed form – Shows the features of both palpebral and bulbar types.

VKC is thought to be an allergic disorder in which IgE mediated mechanism play a role. Such patients often give family history of other atopic diseases such as hay fever, asthma or eczema, and their peripheral blood shows eosinophilia and increased serum IgE levels.

  • Age and sex – 4–20 years; more common in boys than girls.
  • Season – More common in summer. Hence, the name Spring catarrh is a misnomer. Recently it is being labelled as Warm weather conjunctivitis.
  • Climate – More prevalent in the tropics. VKC cases are mostly seen in hot months of summer, therefore, more suitable term for this condition is "summer catarrh" Ref.[3]

  • Conjunctival epithelium undergoes hyperplasia and sends downward projection into sub-epithelial tissue.
  • Adenoid layer shows marked cellular infiltration by eosinophils, lymphocytes, plasma cells and histiocytes.
  • Fibrous layer show proliferation which later undergoes hyaline changes.
  • Conjunctival vessels also show proliferation, increased permeability and vasodilation.

Classification

Based on severity, authors have classified VKC into clinical grades:[4]

Grade 0 - Absence of symptoms

Grade 1 MILD - Symptoms but no corneal involvement

Grade 2 MODERATE - Symptoms with photophobia but no corneal involvement

Grade 3 SEVERE - Symptoms, photophobia, mild to moderate SPK's OR with Diffuse SPK or corneal ulcer

  • Local therapy – Topical steroids are effective. Commonly used solutions are of fluorometholone, medrysone, betamethasone or dexamethasone. Mast cell stabilizers such as sodium cromoglycate (2%) drops 4–5 times a day are quite effective in controlling VKC, especially atopic ones. Azelastine eyedrops are also effective. Topical antihistamines can be used. Acetyl cysteine (0.5%) used topically has mucolytic properties and is useful in the treatment of early plaque formation. Topical Cyclosporine is reserved for unresponsive cases.[citation needed]
  • Systemic therapy – Oral antihistamines and oral steroids for severe cases.
  • Treatment of large papillae – Cryo application, surgical excision or supratarsal application of long-acting steroids.
  • General measures include use of dark goggles to prevent photophobia, cold compresses and ice pack for soothing effects, change of place from hot to cold areas.
  • Desensitization has also been tried without much rewarding results.
  • Treatment of vernal keratopathy – Punctuate epithelial keratitis require no extra treatment except that instillation of steroids should be increased. Large vernal plaque requires surgical excision. Ulcerative vernal keratitis require surgical treatment in the form of debridement, superficial keratectomy, excimer laser therapeutic keratectomy, as well as amniotic membrane transplantation to enhance re-epithelialisation.
  • Recently treatment with tacrolimus ointment (0.1%) used topically twice daily is showing encouraging results.

  1. ↑ Bruschi, Gaia; Ghiglioni, Daniele Giovanni; Cozzi, Laura; Osnaghi, Silvia; Viola, Francesco; Marchisio, Paola (2023-09-02). "Vernal Keratoconjunctivitis: A Systematic Review". Clinical Reviews in Allergy & Immunology. 65 (2): 277–329. doi:10.1007/s12016-023-08970-4. ISSN 1559-0267. PMC 10567967. PMID 37658939.
  2. ↑ Cameron, J. A. (June 1995). "Shield ulcers and plaques of the cornea in vernal keratoconjunctivitis". Ophthalmology. 102 (6): 985–993. doi:10.1016/s0161-6420(95)30925-6. ISSN 0161-6420. PMID 7777308.
  3. ↑ Shah, Syed Imtiaz Ali (2014). Concise Ophthalmology (4th ed.). Paramount. p. 31. ISBN 978-969-637-001-7.
  4. ↑ S Gokhale, Nikhil (2015-06-27). "Vernal Keratoconjunctivitis Grading System and Step Ladder Management Approach". Delhi Journal of Ophthalmology. 25 (2): 85–89. doi:10.7869/djo.84.