Vernal Keratoconjunctivitis VKC

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Vernal Keratoconjunctivitis (VKC)

• It is a chronic , bilateral conjunctival
  inflammatory condition found in individuals
  predisposed by their atopic background. It is
  recurrent, interstitial inflammation of the
  conjunctiva of periodic seasonal incidence, self
  limiting disease/ condition usually due to
  exogenous allergens.

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• Characterized by flat topped papillae usually on
  the tarsal conjunctiva resembling cobble stones
  in appearance , a gelatenous hypertrophy of the
  limbal conjunctiva, either discrete or confluent,
  and a distinctive type of keratitis , associated
  with itching , redness of the eyes lacrimation
  and mucinous or lardaceous discharge usually
  containing eosinophils

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Epidemiology

• Sporadically occurring with a wide geographical
  incidence. Its more common in India and the
  tropics than in U.K. Colored races are
  particularly prone to limbal form of disease.
• It is essentially a disease of youth occurring
  most frequently between ages of 6 and 20 years.

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• Sex incidence Very high percentage of cases are
  seen in males.
• Family History of allergy is found in 40 60
  cases.

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Etiology

• Three theories
• 1. Due to action of physical factors (as heat,
  humidity and light)
• 2. Disorder of the endocrine glands associated
  with vagotonic state
• 3. manifestation of an allergic condition. Most
  affected people show a marked hypersensitivity to
  a variety of antigens (pollen, animal inhalants,
  ingestants etc)

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Symptoms

• Severe itching, photophobia, foreign body
  sensation, ptosis, thick mucous discharge,
  blepharospasm, burning, and typical stringy
  discharge .
• Discharge is scanty, thick, ropy and lardaceous,
  dirty white or cream colored.

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Signs

• The signs are confined to conjunctiva and cornea
  the skin of the lids are not involved.
• Types
• Palpabral form
• Limbal/ Bulbar form
• Mixed type

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• Palpabral VKC
• Conjunctiva develops a papillary response in the
  upper tarsal conjunctiva. Conjunctiva is
  congested later on becomes milky.
• Tarsal papillae are discrete larger than 1 mm in
  diameter, flat tops , they are cobblestone in
  appearance.

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Limbal / Bulbar Form

• In limbal or bulbar form the first change is
  usually a thickening, broadening and
  opacification of the limbus which overrides the
  corneal periphery as a semi-translucent hood.
  This develop mostly at the upper margin of the
  cornea
• Limbal papillae tend to be gelatinous and
  confluent

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• Limbal Nodules Their most common site is in the
  palpabral aperture, nasally and temporally. In
  the raised mass, whitish Horner- Trantass spots
  may occur at any stage. Horner Trantas dots are
  collection of epithelial cells and eosinophils.
• These changes may lead to superficial corneal
  vascularization.

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Corneal Findings

• Punctate Epithelial Keratitis
• Horizontally oval ulcer in upper part of cornea
  called Shield Ulcer
• Peripheral superficial gray white deposition
  termed Pseudogeronton.

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Pathogenesis

• Biopsy of tarsal papilla in VKC reveals that
  epithelium contain large number of mast cells and
  eosinophils. Substantia properia contains
  elevated number of mast cells, also contains CD4
  T cells. Mast cells contains basic fibroblast
  growth factor
• Cytology shows more eosinophils and neutrophils,
  IgE and IgG have been isolated from tears.
  Histamins and trytase are elevated in tears
• Protein deposition diffusely in conjunctiva

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• The flat-topped nodules are hard , and consist
  chiefly of dense fibrous tissue , but the
  epithelium over them is thickened , giving rise
  to the milky hue. Histologically they are
  hypertrophied papillae, not follicle. Eosinophils
  are present in them in great numbers. In addition
  , infiltration with lymphocytes, plasma cells ,
  macrophages, and basophils may also be seen.

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Diagnosis

• History
• Clinical findings (young boys living in warm
  climates presenting with intense photophobia,
  ptosis and gaint papillae)

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TREATMENT

• Avoidance of allergen
• Local Treatment
• a. Steroids Patients with significant seasonal
  exacerbation , a short term high dose pulse
  regimen of topical steroid is necessary.
  Dexamethasone 0.1 or Prednisolon Phosphate 1 ,
  8 times for one week brings excellent result,
  tapered rapidly.

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• b. Mast Cell stabilizer Cromolyn sodium, a
  mast cell stabilizer or a dual acting drug such
  as Olopatidine, Ketotifen or Azelastine (mast
  cell stabilization and antihistamine)
• c. Topical Cyclosporin-A (0.05) twice daily,
  it decreases the release of interlukin-2, reduces
  expansion of T cell clones.

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• Treatment of Corneal Shield Ulcer
• Antibiotic- steroid ointment and occlusion. If
  plaque forms superficial keratectomy
• Phototherapeutic Keratectomy (PTK) and
  Keratectomy with amniotic membrane graft
  placement.

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• Surgical Treatment
• Cryo-ablation of upper tarsal cobble stones
  but may lead to lid and tear film abnormalities.
• Injection of short term or long term acting
  steroids into tarsal papilla has been shown
  effective in reducing their size.

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• 3. Systemic Treatment
• a. Non sedating antihistaminic
• b. Oral Aspirin (high dose of 2400 mgm daily)
• 4. Climatotherapy