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

Abstract

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: A Systematic Review

“…No relapse was observed after treatment suspension Low Callet et al [ 160 ] 2018 France 2 8.0 To describe omalizumab use in VKC and asthma patients Monthly omalizumab therapy permitted VKC and asthma control in both patients Low Westland et al [ 161 ] 2018 Netherlands 3 11.0 To describe an intense regimen of 0.05% cyclosporine for vernal shield ulcers Cyclosporine 8 times a day treatment provided quick resolution of the shield ulcers and complete re-epithelialization Low Maharana et al [ 149 ] 2021 India 11 13.7 To describe the combined topical cyclosporine (CsA) 0.1% and tacrolimus 0.03% use in VKC Combined therapy allowed an improvement in VKC signs and symptoms ( p < 0.001) High Stock et al [ 17 ] 2020 Brazil 2 5.5 To report two cases of corneal shield ulcer treated which surgical debridement In both cases, surgical debridement was curative and definitive in the 7-month follow-up period. Shield ulcer did not recur Medium Patil and Mehta [ 162 ] 2022 Singapore 4 9.8 To report the long-term outcomes of patients with refractory VKC who underwent surgical excision of giant papillae with mitomycin C 0.02% and amniotic membrane transplantation (AMT) Surgical excision of GP in combination with mitomycin C and AMT, in refractory VKC, is a good treatment option with better clinical outcomes over a longer follow-up Medium N/A non-available information …”

“…Similarly, none of the analyzed case series completely fulfilled the checklist criteria, scoring 9 out of 10 on the JBI Critical Appraisal Checklist for Case Series [ 15 ]. Two studies (Maharana et al [ 149 ], Patil et al [ 162 ]) described inclusion criteria in detail. Only one study (Maharana et al [ 149 ]) performed a consecutive inclusion of the participant, although not all the consecutive patients were included in the study, and performed a statistical analysis of the results that emerged.…”

“…No recurrence of limbal stem cell deficiency was observed None Kate et al [ 173 ] 2022 India Case report 1 32 The patient underwent excision of the conjunctival keratinization in both eyes. The resultant bare areas were covered with conjunctival autografts None Patil and Mehta [ 162 ] 2022 Singapore Case series 4 9.8 Surgical excision of giant papillae in combination with mitomycin C and amniotic membrane transplantation in refractory VKC is a good treatment option with better clinical outcomes over a longer follow-up None Senthil et al [ 153 ] 2022 India Retrospective observational study 82 15.8 The surgical success for trabeculectomy, trabeculectomy with mitomycin C, and combined trabeculectomy with cataract extraction is similar at 5 years. Chronic VKC and long‑term steroid use are associated with surgical failure None Arora et al [ 154 ] 2023 India Retrospective observational study 3 17.0 One year after repeat deep anterior lamellar keratoplasty (DALK) in patients of previous failed DALK, best-corrected visual acuity improved from 20/120 to 20/30 in all except one patient None N/A non-available information …”

Surgical Antimicrobial Prophylaxis in Patients of Neonatal and Pediatric Age Subjected to Eye Surgery: A RAND/UCLA Appropriateness Method Consensus Study

“…The work of Iyer and colleagues reported the successful experimental therapy of an allo-Simple Limbal Epithelial Transplantation (allo-SLET) in 3 adult subjects after surgical removal of superficial squamous neoplasia, with postoperative use of 0.04% mitomycin C, 2 cycles, every other week [93]. Patil's group reported good success in the combination of amniotic membrane transplantation and 0.02% mitomycin applied to resected papillae in 4 pediatric patients (7-14 years old) treated for vernal keratoconjunctivitis, but did not mention pre-and intra-operative antibiotic therapy [94].…”