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CLINICAL MANAGEMENT GUIDELINES

Vernal Keratoconjunctivitis (VKC, Spring catarrh)



Vernal Keratoconjunctivitis (Spring catarrh)
Version 10 13.10.10 1 of 2
College of Optometrists


Aetiology Uncommon allergic disorder of children
Complex immune response 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 year-round
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 severity of symptoms is often asymmetrical
Signs Stringy white mucous exudate
Palpebral, limbal and corneal manifestations:
Palpebral
Hyperaemia, oedema (chemosis) and cellular infiltration of conjunctiva
when active
Giant papillary hypertrophy (papillae 1mm or greater in diameter) of
upper tarsus (cobblestone appearance)
Limbal
Hyperaemic, oedematous, thickened limbus
Trantas 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 Bowmans layer, preventing re-epithelialisation)
Subepithelial scarring (often ring-shaped)
NB: the signs are often asymmetrical
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 when acute
Pharmacological Mast cell stabilisers e.g. gutt. sodium cromoglicate 2%, gutt. lodoxamide
0.1%, gutt. nedocromil sodium 2%
Acute exacerbations may require topical steroid, plus regular monitoring:
hence need to refer to Ophthalmologist
Management Category If there is active limbal or corneal involvement:
A3: First aid measures followed by urgent referral to an
Ophthalmologist
Milder cases (without active limbal or corneal involvement):
B1: Possible prescription of drugs; routine referral
Possible management by Ophthalmologist
Usually topical steroid. Other drugs used include immunosuppressants
(ciclosporin) and mucolytics (acetyl cysteine).
CLINICAL MANAGEMENT GUIDELINES

Vernal Keratoconjunctivitis (VKC, Spring catarrh)

Vernal Keratoconjunctivitis (Spring catarrh)
Version 10 13.10.10 2 of 2
College of Optometrists


Manual or laser surgery may be required for the removal of corneal
plaque
Evidence base
Mantelli F, Santos MS, Petitti T, Sgrulletta R, Cortes M, Lambiase A,
Bonini S: Systematic review and meta-analysis of randomised clinical
trials on topical treatments for vernal keratoconjunctivitis.
Br J Ophthalmol 2007;91:165661
Authors conclusion: currently available topical drugs are effective in
treating acute phases of VKC. However, there is a lack of evidence to
support the recommendation of one specific type of medication for
treating this disorder
(The Oxford 2011 Levels of Evidence = 1)

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