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)