Management of Vernal Keratoconjunctivitis in Children in the United Kingdom: A Review of the Literature and Current Best Practice Across Six Large United Kingdom Centers.

Vernal keratoconjunctivitis (VKC) is a form of ocular allergy primarily affecting children. Considered a rare disease in Europe, its prevalence varies by geographic region and is poorly studied in the United Kingdom. There is considerable national variation in the management of VKC within the United Kingdom, risking misdiagnosis and delays to treatment for some children. This can significantly impact their quality of life, with the potential for lasting negative consequences. Based on discussions between experienced clinicians from six large centers across the United Kingdom, this article describes best practice recommendations for United Kingdom settings, including principles for diagnosis, referral, initial and long-term management, and supportive care. Recommendations include guidance on referral timing, which should depend on VKC severity, and a stepwise approach to treatment. Joint management by primary care and secondary care is recommended and the importance of supportive care, including emotional support and outreach to schools, is highlighted. Because frequent flareups are common in VKC, it is essential that families have access to the information they need to manage the disease and routes to access rapid care if needed. A thorough understanding of the nature of VKC, its triggers, and how best to manage it, by both patients and their families, is critical to ensuring appropriate management and to improving patient outcomes. [J Pediatr Ophthalmol Strabismus. 2023;60(1):6-17.].

Understanding the Journey of Patients With Vernal Keratoconjunctivitis: A Qualitative Study of the Impact on Children and Families.

PURPOSE: To understand the impact of vernal keratoconjunctivitis (VKC), a chronic allergic inflammation of the ocular surface that primarily affects children and young adults, on daily life. METHODS: This qualitative study used an interpretative phenomenological analysis approach. Paired interviews with patients and parents were conducted in the participants' homes. Interviews continued until thematic saturation (no new information arising) was obtained. Nine patients and their families were interviewed. The patients were between 5 and 13 years old with disease severity ranging from mild to severe. RESULTS: Several consistent themes emerged from the study, including the significant impact of VKC on schooling and family life. Families of children with VKC experience delays in receiving an accurate diagnosis and a lack of information and emotional support, which led the parents to report living in a constant state of tension about whether they were doing the right thing for their child. Although many children with VKC also have other atopic conditions, there is no cohesive approach to clinical care. CONCLUSIONS: VKC poses a significant burden on the lives of patients and their families. Greater awareness among clinicians is essential for early diagnosis and treatment and to prevent potential sight-threatening complications. The chronic nature of VKC necessitates a holistic approach to patient care to address the multiple clinical and emotional needs of the children and their families.[J Pediatr Ophthalmol Strabismus. 2021;58(5):298-303.].

Defining the limits of normal conjunctival fornix anatomy in a healthy South Asian population.

PURPOSE: Quantifying the extent of conjunctival fibrosis for documentation of progression in conjunctival scarring disease is a clinical challenge. Measurement of forniceal foreshortening facilitates monitoring of these disorders. This study aims (1) to define the limits of the normal human conjunctival fornices and how these alter with age and (2) to provide normative data for upper and lower fornix depths (FDs) and fornix intercanthal distance (FICD) within a healthy South Asian, racially distinct population. DESIGN: Epidemiologic, cross-sectional study. PARTICIPANTS: A total of 240 subjects with national origins from South Asia, with no known ocular history and normal adnexal and conjunctival examination, aged 20 to 80 years. METHODS: An FICD modification of a custom-designed fornix depth measurer (FDM) was validated and used for measurement of both lower and upper FDs together with FICDs in 480 healthy eyes with no ocular comorbidities. Data were analyzed using repeated-measures analysis of variance and presented as means with 95% confidence intervals (CIs). MAIN OUTCOME MEASURES: Mean lower and upper FDs and FICD for the entire cohort, stratified according to age decade and sex. RESULTS: For this South Asian population, the overall upper and lower FDs were 15.3 mm (95% CI, 14.9-15.6) and 10.9 mm (95% CI, 10.7-11.1), respectively, with FICD defined as 32.9 mm (95% CI, 32.5-33.4) (upper) and 31.7 mm (95% CI, 31.3-32.1) (lower). With increasing age, a progressive reduction of all measured parameters (P < 0.001) was noted, with female subjects having significantly shallower fornices (upper FD, P < 0.001; lower FD, P < 0.001; upper FICD, P = 0.081; and lower FICD, P = 0.015). CONCLUSIONS: This is the first study to define the limits of normal upper FD and FICDs in any population group. Our study demonstrates sex variations and progressive conjunctival shrinkage with age. Although it provides important, objective data for normal forniceal anatomy, further study is recommended in other populations to confirm the generalizability of these data or to enable normal comparative datasets for the assessment of conjunctival scarring disorders among all anthropological groups.

Acute dacryocystitis associated with epstein-barr virus infection.

Acute dacryocystitis is a rare complication of infectious mononucleosis with only three previous reports in the English literature. We present two further children with acute dacryocystitis and clinical and laboratory features of Epstein-Barr Virus related infectious mononucleosis. Both were treated with systemic antibiotics and one child additionally required surgical drainage of a lacrimal sac abscess. Both children made a complete recovery without any lacrimal symptoms. Acute dacryocystitis is uncommon in children without a history of congenital nasolacrimal duct obstruction, and an underlying systemic condition such as infectious mononucleosis should be suspected. In such patients, dacryocystitis can be expected to resolve without symptoms of nasolacrimal duct obstruction and dacryocystorhinostomy is seldom required.

Late onset of subfoveal choroidal neovascularisation following cerebral radiotherapy.

A report of choroidal neovascularisation (CNV) associated with radiation retinopathy. A 43-year-old Caucasian man presented with a 4-week history of sudden loss of central vision in the left eye, 8.5 years following radical radiotherapy for left tempero-parietal anaplastic astrocytoma. His visual acuity was 6/6 in the right eye and 6/60 in the left eye. Ophthalmoscopy of the left eye showed central macular pigmented area surrounded by subretinal fluid, haemorrhage and exudates. Fundus fluorescein angiography revealed left subfoveal CNV with surrounding macular oedema and peripheral retinal ischaemia. Radiation retinopathy associated CNV is a late ocular complication of cerebral radiotherapy. It should be investigated as a possible aetiology of severe visual loss in long-term survivors of cerebral tumours who have previously received radiotherapy.

Diabetic retinopathy in pregnancy.

Pregnancy in a diabetic woman brings about many changes that can lead to the development of diabetic retinopathy (DR) or worsening of pre-existing disease. In some patients this may develop into sight threatening disease which, if not treated adequately, can cause devastating visual impairment. There is a lack of established guidelines for screening these patients during pregnancy. In this article we discuss the physiological changes during pregnancy that contribute to worsening of diabetic retinopathy and review the relative contribution of risk factors to the underlying pathological processes. It is important to identify and treat any pre-existing retinopathy in diabetic women considering pregnancy and optimise glycaemic control prior to conception. Rapid tightening of glycaemic control after conception is associated with a less favourable outcome. Based on the existing literature we suggest guidelines for diabetic retinopathy screening for women during pregnancy. Established sight-threatening retinopathy should be treated at an earlier stage in pregnant women compared to non-pregnant diabetics with a similar disease.