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CLINICAL MANAGEMENT GUIDELINES Vernal Keratoconjunctivitis (Spring catarrh) Aetiology Uncommon allergic disorder of children Complex immune reaction with raised IgE levels in the tears and serum, and mast cells and eosinophils in the conjunctival epithelium Predisposing factors Onset usually before 10 years of age; M>>F Seasonal exacerbations (hence name) but condition may be active yearround if severe Patients usually atopic with a history of eczema and asthma Often a family history of atopic disease Symptoms ocular itching watering mucoid stringy discharge blurred vision photophobia difficulty opening eyes on waking NB: the symptoms are often asymmetrical in the two eyes Signs Stringy white mucous exudate Palpebral, limbal and corneal manifestations: Palpebral hyperaemia and chemosis of conjunctiva when active giant papillary hypertrophy (papillae 1mm or greater in diameter) of upper tarsus (‘cobblestone’ appearance) Limbal hyperaemic, oedematous, thickened limbus Trantas’s Dots (discrete white superficial accumulations of eosinophils and degenerating epithelial cells) Corneal (usually in upper third) punctate epithelial keratopathy macro-erosion (coalescent epithelial loss) plaque (deposited on Bowman’s layer, preventing reepithelialisation) subepithelial scarring (often ring-shaped) NB: the signs are often asymmetrical in the two eyes These patients may also have keratoconus and/or atopic cataract Differential diagnosis Atopic keratoconjunctivitis (usually in adults; around puberty, VKC may metamorphose into this disease) Management by Optometrist Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere Non pharmacological Cold compresses may reduce acute symptoms (GRADE*: Level of evidence=low, Strength of recommendation=strong) Pharmacological Mast cell stabilisers e.g. gutt sodium cromoglicate 2% qds, gutt lodoxamide 0.1% qds Because of the sight-threatening nature of this condition, and the frequent need for other medical specialist involvement, maintain low threshold for referral to the Ophthalmologist (GRADE*: Level of evidence=moderate, Strength of recommendation=strong) Management Category If there is active limbal or corneal involvement: A3: First aid measures followed by urgent referral (within one week) to an Ophthalmologist Milder cases (without active limbal or corneal involvement): B1: Possible prescription of drugs; routine referral Initial management followed by routine referral if mast cell stabilizers fail Vernal Keratoconjunctivitis (Spring catarrh) Version 11, Page 1 of 2 Date of search 07.12.14; Date of revision 20.02.15; Date of publication 28.05.15; Date for review 06.12.16 © College of Optometrists CLINICAL MANAGEMENT GUIDELINES Vernal Keratoconjunctivitis (Spring catarrh) to provide symptomatic relief. Consider co-management with Ophthalmologist. VKC requires careful monitoring for sight-threatening complications Possible management by Ophthalmologist Usually topical steroid. Other topical drugs used include immunosuppressants (e.g. ciclosporin) and mucolytics (acetyl cysteine). Manual or laser surgery may be required for the removal of corneal plaque Evidence base *GRADE: Grading of Recommendations Assessment, Development and Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm) Sources of evidence Avunduk AM, Avunduk MC, Kapicioglu Z, Akyol N, Tavli L. Mechanisms and comparison of anti-allergic efficacy of topical lodoxamide and cromolyn sodium treatment in vernal keratoconjunctivitis. Ophthalmology. 2000;107:1333-7 De Smedt S, Nkurikiye J, Fonteyne Y, Tuft S, De Bacquer D, Gilbert C, Kestelyn P. Topical ciclosporin in the treatment of vernal keratoconjunctivitis in Rwanda, Central Africa: a prospective, randomised, double-masked, controlled clinical trial. Br J Ophthalmol. 2012;96:323-8 Kumar S.Vernal keratoconjunctivitis: a major review. Acta Ophthalmol. 2009;87:133-47 Mantelli F, Santos MS, Petitti T et al: Systematic review and metaanalysis of randomised clinical trials on topical treatments for vernal keratoconjunctivitis. Br J Ophthalmol. 2007;91:1656-61 LAY SUMMARY Vernal Keratoconjunctivitis (VKC), also known as Spring Catarrh, is a rare but serious allergic disease affecting the eyes of young children, especially boys. It usually begins before the age of 10 years and often disappears at puberty, though it may change at that time into another allergic eye disease known as Atopic Keratoconjunctivitis. Children with VKC complain of itching of the eyes, watering and a stringy discharge. Their vision may be blurred and they may be excessively sensitive to light. One characteristic symptom is that they may have great difficulty in opening their eyes on awaking, and this and the very distracting effect of the condition may cause them to miss school. VKC produces inflammation of the eye surface. On the underside of the upper eyelids, bumps shaped like tiny cobblestones appear. Substances released from this tissue can cause damage to the cornea (the clear window of the eye). Sometimes a whitish deposit may accumulate on the cornea. VKC is not a simple allergic condition like Seasonal Allergic Conjunctivitis as it involves various different types of immune reaction. Its treatment therefore involves drugs of a number of types, including steroids and immunosuppressants. This is why many cases need to be referred to the ophthalmologist for management. Surgery is sometimes needed when plaque has accumulated on the cornea. Vernal Keratoconjunctivitis (Spring catarrh) Version 11, Page 2 of 2 Date of search 07.12.14; Date of revision 20.02.15; Date of publication 28.05.15; Date for review 06.12.16 © College of Optometrists