Download Vernal Keratoconjunctivitis (Spring catarrh)

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