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

Long-term outcomes and risk factors for failure of glaucoma filtering surgery in eyes with vernal keratoconjunctivitis and steroid-induced glaucoma

Purpose: To report outcomes and assess the risk factors for failure of trabeculectomy (trab), trabeculectomy with mitomycin?C (trabMMC), and combined trabeculectomy with cataract extraction (CT) in vernal keratoconjunctivitis (VKC) eyes with steroid?induced glaucoma (SIG). Methods: Trab was performed in 45 eyes of 30 subjects, trabMMC in 36 eyes of 25 subjects, and CT in 34 eyes of 27 subjects. Success was complete when intraocular pressure (IOP) was between 6 and 21 mm Hg without anti?glaucoma medications (AGM) and qualified with AGM. Results: Median age (14 vs. 16.3 and 17.4 years) was significantly less in the trab cohort (P = 0.007). Majority (88%–93%) were male (P = 0.78). Preoperatively, median duration of steroid usage was >2 years (P = 0.52), mean IOP (32, 29.4, and 28.4; P = 0.26) and median cup:disc ratio (CDR) (0.9; P = 0.27) were similar in the three groups. Complete success (76%, 71%, and 66% at 5 years; P = 0.91), and qualified success (88%, 97%, and 94% at 5 years; P = 1.0) with trab, trabMMC, and CT, respectively, were similar. Preoperative factors significantly associated with qualified failure (multiple logistic regression) were older children, longer duration of VKC, longer duration and mixed type of steroid use (all P < 0.001) and larger CDR (P < 0.02). At the last follow?up, 38% in trab, 33% in trabMMC, and 50% eyes in CT were blind (visual acuity ?20/400 and/or visual field ?10°) due to glaucoma (P = 0.33). Conclusion: The surgical success for all three types of surgery was similar at 5?years. Chronic VKC and long?term steroid use were associated with surgical failure. The majority had advanced disease and a significant proportion were blind due to glaucoma.

Clinical presentation of vernal keratoconjunctivitis in an immunocompromised patient: a case report

Vernal keratoconjunctivitis(VKC)is a chronic bilateral inflammation of the conjunctiva, commonly associated with a personal or family history of atopy. It is characterized by severe itching, foreign body sensation, thick ropy discharge, photophobia and conjunctival injection. VKC has palpebral, limbal and mixed forms. The classical conjunctival sign in palpebral VKC is the presence of giant papillae, which are predominantly seen on the superior tarsal conjunctiva. The limbal form occurs in dark skinned individuals and the papillae tend to occur at the limbus and have a thick gelatinous appearance. Clinical findings and laboratory investigations support the presence of IgE mediated type1 hypersensitivity reaction. Involvement of CD4 T helper (Th2) driven type IV hypersensitivity has also been confirmed. There has been an increase in the prevalence of allergic disorders in recent years and exaggerated manifestations of these diseases have been recognized in patients living with Human immunodeficiency virus

Ocular allergy in the Asia Pacific region

Allergic conjunctivitis (AC) represents a spectrum of disorders, comprising seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), atopic keratoconjunctivitis (AKC), vernal keratoconjunctivitis (VKC) and giant papillary conjunctivitis. Of these ocular allergy types, SAC and PAC are the most common. The most striking difference within this group of ocular diseases is that SAC and PAC remain self-limited without ocular surface damage, while AKC and VKC can compromise the cornea, causing ulcers and scarring and can ultimately lead to vision loss. Data on AC in the Asia Pacific is scarce however some understanding of prevalence of the condition has been obtained from the International Study of Asthma and Allergies in Childhood (ISAAC) studies and more recently from the Allergies in Asia Pacific study as well as some information from individual country surveys. Unfortunately none of this data has been collected using validated survey instruments specifically designed for AC. Surveys such as ISAAC have been predominantly concerned with respiratory allergic symptoms with questions added that incorporate some ocular symptoms. These questionnaires do not detect individuals who may have AC in the absence of allergic rhinitis. Using hospital ophthalmology outpatient populations for prevalence studies of ocular allergy immediately introduces a bias towards the more severe, complex forms of the condition as patients with the milder forms of SAR and PAR will rarely present to a hospital outpatient clinic. There is a real need for the development of validated questionnaires specifically addressing ocular allergy. There are no widely accessible studies examining prevalence of the complex forms of ocular allergy (AKC, VKC) in Asia Pacific region. This review will provide an overview of ocular allergy, its classification, clinical presentation and differential diagnosis, and will also discuss what is known about the epidemiology of ocular allergy in the Asian Pacific region.

Effect of Treatment With Excision of Papillae and Supratarsal Triamcinolone Injection on Refractory Vernal Keratoconjunctivitis

PURPOSE: To evaluate the therapeutic effect of the combined treatment of excision of the papillae and a supratarsal injection of triamcinolone on refractory vernal keratoconjunctivitis (VKC). METHODS: Twenty-three eyes of 14 patients with refractory vernal keratoconjunctivitis were included. Patients were treated with the combined excision of papillae and supratarsal injection of triamcinolone. Best corrected visual acuity (BCVA), intraocular pressure, symptoms of itching, tearing, discomfort, secretion and epiphora, and signs including limbal hypertrophy, hyperemia, papilla size, keratitis, corneal neovascularization and blepharitis were evaluated before and two weeks, four weeks, and eight weeks after treatment. The CCL11 level in the tears of each eye were analyzed before and two weeks after treatment. RESULTS: The mean scores of subjective symptoms and objective signs as well as BCVA were significantly improved two weeks after treatment. CCL11 levels in the tears were 389.5+/-474.9 pg/ml before treatment and were undetectable two weeks after treatment. Improvement of symptom and sign parameters was maintained up to eight weeks after treatment. However, seven eyes (30.4%) recurred within two weeks after treatment. CONCLUSIONS: Combined excision of the papillae and a supratarsal injection of triamcinolone may be effective in the treatment of refractory VKC.