Keratoconjunctivitis vernalis

Abstract

Vernal keratoconjunctivitis (VKC) is a bilateral, usually seasonally recurrent inflammation of the conjunctiva. Clinically characteristic findings are tarsal giant conjunctival papillae (> 1 mm) and/or limbal gelatinous changes (Trantas dots). The underlying etiology and pathophysiology of VKC remains unclear; however, clinical findings and immunohistochemical studies suggest a complex, both IgE-dependent and IgE-independent immune-mediated etiology. Several predisposing conditions include endocrine, genetic, neurogenic, environmental and socioeconomic risk factors. Mast cell stabilizers, antihistamines and topical corticosteroids are often used during acute flare-ups in VKC; however this approach is unsatisfactory for controlling severe cases and avoiding recurrences. Immunomodulatory agents, such as cyclosporin A and tacrolimus are promising alternative agents for long-term management. In most children the clinical course of VKC is self-limiting and may disappear following puberty; however, some VKC patients will face sight-threatening complications which are mainly due to corneal involvement and iatrogenic damage caused by prolonged corticosteroid treatment.

The allergic eye

“…The overuse of prescribed corticosteroids may lead to iatrogenic corneal damage and cataract formation, justifying that these patients be referred to an ophthalmologist for management. [14] Giant papillary conjunctivitis is a disease mostly affecting young adults wearing contact lenses. The pathogenesis is therefore not exclusively a result of immunological mechanisms, but includes a mechanical component.…”

Treating Severe Pediatric Keratoconjunctivitis with Topical Cyclosporine A

“…The most important differential diagnosis in children is VKC; this accounts for 0.1-1 % of all eye diseases in Central Europe, with a clear increase in incidence from north to south [3]. Etiologies that come into consideration include a genetic predisposition, an allergic aspect (seasonal exacerbation), and environmental factors [4].…”

“…Atopy is present in the family history in approximately two thirds of cases. Typical clinical findings are conjunctival hyperemia, mucosal hypersecretion, giant papillae on the underside of the upper eyelid (pathognomonic in the case of the tarsal form), and/or Horner-Trantas dots (eosinophils, granulocytes and epithelial cell deposits), primarily in the area of the upper limbus (limbal form) [3]. The corneal manifestations include superficial punctate keratitis and erosions, and, in advanced stages, shield ulcer.…”

Omalizumab in three children with severe vernal keratoconjunctivitis

“…Early stages of VKC might be difficult to discriminate from atopic keratoconjunctivitis (AKC), often presenting together with atopic dermatitis as comorbidity. VKC usually occurs within the first decade of life, predominantly in young males without eyelid involvement in contrast to AKC showing additional blepharoconjunctivitis [2]. An Italian prospective study (patients 3-100 years of age) estimated a VKC prevalence of 6.5%; 64.5% of these patients were under 14 years of age [3].…”

“…Omalizumab as a monoclonal anti-IgE antibody blocking the IgE high-affinity receptor on mast cells and basophils and, thus, mediator release was used in the treatment of several patients with severe AKC and VKC [12][13][14][15] with variable outcome. In case of seasonal and even perennial VKC with associated sensitizations the causative approach of subcutaneous immunotherapy should be introduced despite limited evidence in VKC [2,4,8,16]. In summary, a significant proportion of patients with serious VKC under topical treatment suffer from recurrent insufficiently controlled symptoms, which may result in fibrotic remodelling of the eye, followed by visual impairment.…”