Vernal Keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a chronic, bilateral, severe allergic inflammation of the conjunctiva and cornea mediated by Th2 lymphocytes, eosinophils and mast cells.

• Typically affects boys aged 5 to 20 years, male to female about 3:1, in warm, dry climates (Mediterranean, Middle East, tropical Africa, India), with spring and summer peaks and resolution after puberty.
• Atopy in about 50 percent of patients.
• Types: palpebral (giant cobblestone papillae on upper tarsus), limbal (Horner-Trantas dots, gelatinous limbal nodules), and mixed.
• Sight threatening from corneal complications.

• Severe itching, photophobia, thick ropy mucus discharge, tearing, ptosis, foreign body sensation, blepharospasm.
• Giant papillae (over 1 mm) on the upper tarsal conjunctiva giving a cobblestone appearance.
• Limbal form: gelatinous thickening and white Horner-Trantas dots (eosinophil aggregates).
• Corneal involvement: superficial punctate keratitis, epithelial macroerosions, shield ulcer (oval superior epithelial defect with plaque of mucus and fibrin at the base), pseudogerontoxon (limbal scarring), keratoconus.
• Complications: corneal scarring, secondary infection, steroid induced glaucoma and cataract, amblyopia in young children.

• Clinical, from the age, season, itch, giant papillae and limbal changes.
• Conjunctival scraping showing eosinophils and eosinophilic granules; tear IgE raised; serum IgE, skin tests as supportive.
• Corneal topography to detect keratoconus. Fluorescein to stain ulcers.
• Intraocular pressure and lens check in patients on steroids.
• Exclude other papillary conditions: giant papillary conjunctivitis, atopic keratoconjunctivitis, bacterial and chlamydial conjunctivitis.

• Environmental measures: cold compresses, avoid allergens, sunglasses, air conditioning, preservative free lubricants hourly to 4 times daily.
• Maintenance: dual action antihistamine and mast cell stabilisers (olopatadine 0.1 percent twice daily, ketotifen 0.025 percent twice daily, lodoxamide 0.1 percent four times daily).
• Topical calcineurin inhibitors as steroid sparing agents: cyclosporine 0.05 to 0.1 percent (up to 2 percent for severe disease in some regions) four times daily, or tacrolimus 0.1 percent twice daily as eye drop or ointment 0.03 percent to lids.
• Acute flares: topical corticosteroid pulses: prednisolone acetate 1 percent or dexamethasone 0.1 percent every 2 to 4 hours for 3 to 7 days then taper; prefer loteprednol or fluorometholone for longer use. Check intraocular pressure every 2 to 4 weeks.
• Supratarsal corticosteroid injection (triamcinolone 20 mg/mL, 0.1 mL) for resistant papillae or shield ulcers.
• Shield ulcer: topical steroid plus antibiotic cover (moxifloxacin 0.5 percent four times daily), lubricants, and surgical debridement (superficial keratectomy) to remove plaque, with amniotic membrane when needed.
• Severe disease: oral prednisolone 0.5 to 1 mg/kg short course, or omalizumab, or dupilumab; large papillae excision or cryotherapy.
• Follow up regularly for intraocular pressure and lens; consider keratoconus screening and cross linking.