Vernal conjunctivitis

Vernal Conjunctivitis

Prof Ariyanto Harsono MD PhD SpA(K)

IntroductionVernal conjunctivitis is chronic inflammation of the outer lining of the eyes.

Is also called Vernal keratoconjunctivitis (VKC)interchangealy is a member of a group of diseases classified as allergic conjunctivites including perennial and seasonal rhinoconjunctivitis, atopic keratoconjunctivitis, and giant papillary conjunctivitis. Vernal conjunctivitieswere considered the expression of a classical type I IgE-mediated hypersensitivity reaction at the conjunctivallevel. More recent clinical observations, however, suggest that other tissues of the eye are also involved in the ocular allergic reaction.

Prof Ariyanto Harsono MD PhD SpA(K) 2

New discoveries regarding the pathogenesis of ocular allergies have clearly indicated that the participation of the entire ocular surface in allergic diseases is not only the consequence of tissue contiguity but derives from a complex exchange of information between these tissues through cell-to-cell communications, chemical mediators, cytokines, and adhesion molecules.


Allergic conjunctivitis subtypes

Vernal Conjunctivitis belongs to Allergic conjunctivitis group.Allergic conjunctivitis may be divided into 5 major subcategories.

Seasonal allergic conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC) are commonly grouped together.

Vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis(AKC), and giant papillary conjunctivitis (GPC) constitute the remaining subtypes of allergic conjunctivitis.

Early diagnosis and treatment will help prevent the rare complications that can occur with this disease.


Etiology

VKC is thought to be an allergic disorder in which IgE mediated mechanism play a role. Such patients often give family history of other atopic diseases such as hay fever, asthma or eczema, and their peripheral blood shows eosinophilia and increased serum IgE levels.


Predisposing Factors

Age and sex – 4–20 years; more common in boys than girls.

Season – More common in summer. Hence, the name Spring catarrh is a misnomer. Recently it is being labelled as Warm weather conjunctivitis.

Climate – More prevalent in the tropics. VKC cases are mostly seen in hot months of summer, therefore, more suitable term for this condition is "summer catarrh".


PathologyConjunctival epithelium undergoes hyperplasia and

sends downward projection into sub-epithelial tissue.

Adenoid layer shows marked cellular infiltration by eosinophils, lymphocytes, plasmacells and histiocytes.

Fibrous layer show proliferation which later undergoes hyaline changes.

Conjunctival vessels also show proliferation, increased permeability and vasodilation.


Clinical ManifestationsSymptoms- VKC is characterized by marked burning and itchy sensations which may be intolerable and accentuates when patient comes in a warm humid atmosphere. Associated symptoms include mild photophobia, lacrimation, stringy discharge and heaviness of eyelids.Signs of VKC can be described in three clinical forms. Palpebral form- Usually upper tarsal conjunctiva of both the eyes

is involved. Typical lesion is characterized by the presence of hard, flat-topped papillae arranged in cobblestone or pavement stone fashion. In severe cases papillae undergo hypertrophy to produce cauliflower-like excrescences of 'giant papillae'.

Bulbar form- It is characterized by dusky red triangular congestion of bulbar conjunctiva in palpebral area, gelatinous thickened accumulation of tissue around limbus and presence of discrete whitish raised dots along the limbus (Tranta's spots).

Mixed form- Shows the features of both palpebral and bulbar types. Prof Ariyanto Harsono MD PhD SpA(K) 8

Burning eyes Discomfort in bright light

(photophobia) Itching eyes The area around the cornea

where the white of the eye and the cornea meet (limbus) may become rough and swollen

The inside of the eyelids (most often the upper ones) may become rough and covered with bumps and a white mucus

Watering eyes


VKC may be subdivided into 2 varieties, as follows: palpebral and limbal. The classic conjunctivalsign in palpebral VKC is the presence of giant papillae. The papillae most commonly occur on the superior tarsal conjunctiva; usually, the inferior tarsal conjunctiva is unaffected. Giant papillae assume a flattop appearance, which often is described as "cobblestone papillae." In severe cases, large papillae may cause mechanical ptosis (drooping eyelid).


Diagnosis

1. In seasonal and perennial allergic conjunctivitis, superficial conjunctival scrapings may help to establish the diagnosis by revealing eosinophils, but only in the most severe cases, since eosinophils are typically present in the deeper layers of the substantia propria of the conjunctiva. Therefore, the absence of eosinophils on conjunctival scraping does not rule out the diagnosis of allergic conjunctivitis.

2. Many investigators have described measurement of tear levels of various inflammatory mediators, such as IgE, histamine, and tryptase, as indicators of allergic activity.


3. Additionally, skin testing by an allergist may provide definitive diagnosis and pinpoint the offending allergen(s).


In vernal keratoconjunctivitis (VKC), conjunctivalscrapings of the superior tarsal conjunctiva and of Horner-Trantas dots show an abundance of eosinophils. Conjunctival scrapings of patients with atopic keratoconjunctivitis (AKC) may demonstrate the presence of eosinophils, although the number is not as significant as that seen in VKC. Additionally, free eosinophilic granules, which are seen in VKC, are not seen in AKC.


TreatmentLocal therapy Topical steroids are effective. Commonly used solutions are fluorometholone, betamethasone or dexamethasone. Mast cell stabilizers such as sodium cromoglycate (2%) drops 4–5 times a day. Common mast cell stabilizers include cromolyn sodium and lodoxamide. Alcaftadine, olopatadine, nedocromil, and ketotifenare mast cell stabilizers and inhibit histamine release.Azelastine eyedrops are also effective. Artificial tears substitutes provide a barrier function and help to improve the first-line defense at the level of conjunctival mucosa. These agents help to dilute various allergens and inflammatory mediators that may be present on the ocular surface, and they help flush the ocular surface of these agents.Acetyl cysteine (.0.5%) used topically has mucolytic properties and is useful in the treatment of early plaque formation. Topical Cyclosporine is reserved for unresponsive cases.


Systemic therapy

Oral antihistamines and oral steroids for severe cases.

Treatment of large papillae- Cryo application, surgical excision or supratarsal application of long-acting steroids.

Vasoconstrictors are available either alone or in conjunction with antihistamines to provide short-term relief of vascular injection and redness. Common vasoconstrictors include naphazoline, phenylephrine, oxymetazoline, and tetrahydrozoline. Generally, the common problem with vasoconstrictors is that they may cause rebound conjunctivalinjection and inflammation. These pharmacologic agents are ineffective against severe ocular allergies and against other more severe forms of allergic conjunctivitis, such as atopic and vernal disease.


Corticosteroidso Corticosteroids remain among the most potent pharmacologic

agents used in the treatment of chronic ocular allergy. They act at the first step of the arachidonic acid pathway by inhibiting phospholipase, which is responsible for converting membrane phospholipid into arachidonic acid.

o Corticosteroids do have limitations, including ocular adverse effects, such as

delayed wound healing, secondary infection, elevated intraocular pressure, and formation of cataract.

In addition, the anti-inflammatory and immunosuppressive affects are nonspecific. As a rule, topical steroids should be prescribed only for a short period of time and for severe cases that do not respond to conventional therapy.


General measures include use of dark goggles to prevent photophobia, cold compresses and ice pack for soothing effects, change of place from hot to cold areas.Desensitization has also been tried without much rewarding results.Treatment of vernal keratopathy- Punctuate epithelial keratitis require no extra treatment except that instillation of steroids should be increased. Large vernal plaque requires surgical excision. Ulcerative vernal keratitis require surgical treatment in the form of debridement, superficial keratectomy, excimer laser therapeutic keratectomy, as well as amniotic membrane transplantation to enhance re-epithelialisation.


Home care measures

Avoid rubbing the eyes, because this can irritate them more.

Cold compresses (a clean cloth soaked in cold water and then placed over the closed eyes) may be soothing.

Lubricating drops may also help soothe the eye.


Immunotherapy

Immunotherapy is a mainstay in the systemic management of allergies. Traditionally, immunotherapy is delivered via subcutaneous injection. However, sublingual (oral) immunotherapy (SLIT) is gaining momentum among allergists. Numerous articles have analyzed the effects of SLIT on allergic conjunctivitis. SLIT may significantly reduce symptoms in children with grass pollen–allergic rhinoconjunctivitis.


Differential Diagnoses

Conjunctivitis, Bacterial

Conjunctivitis, Giant Papillary

Conjunctivitis, Viral

Keratoconjunctivitis, Atopic

Keratoconjunctivitis, Superior Limbic

Keratoconus


PreventionSeasonal and perennial allergic conjunctivitis

Avoidance of the offending antigen is the primary behavioral modification; specific testing by an allergist will identify the responsible allergen(s) and help the individual to establish ways to avoid the allergen. Contact reactions caused by medications or cosmetics are also treated best by avoidance.

Vernal keratoconjunctivitis

As with most type I hypersensitivity disorders, allergen avoidance should be emphasized as the first-line treatment. Although permanent relocation to a cooler climate is not feasible in many cases, it remains a very effective therapy for VKC.

Maintenance of an air-conditioned environment and control of dust particles at home and work may also be beneficial. Local measures, such as cold compresses and periodic instillation of artificial tears, have also been shown to provide temporary relief.


Prognosis

Since allergic conjunctivitis generally clears up readily, the prognosis is favorable. Complications are very rare, with corneal ulcers or keratoconus occurring rarely. Although allergic conjunctivitis may commonly reoccur, it rarely causes any visual loss.


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medication#5. Accessed 28 Nov 2014.2. Vernal conjunctivitis. http://www.nlm.nih.gov/medlineplus/ency/article/001390.htm.

Accessed 28 Nov 2014. 3. Vernal conjunctivitis. http://en.wikipedia.org/wiki/Vernal_keratoconjunctivitis.

Accessed 28 Nov 2014.4. Stock EL. Vernal Keratoconjunctivitis. In: Tasman W, Jaeger EA, eds. Duane's Clinical

Ophthalmology. 2013 ed. Philadelphia, PA: Lippincott, Williams & Wilkins: 2013:vol 4, chap 9.

5. Rubenstein JB, Virasch V. Allergic conjunctivitis. In: Yanoff M, Duker JS, eds. Ophthalmology. 3rd ed. St. Louis, MO: Mosby Elsevier; 2008:chap 4.7.

6. Barney NP, Graziano FM, Cook EB, Stahl JL. Allergic and immunologic diseases of the eye. In: Adkinson NF, Jr., ed. Middleton's Allergy: Principles and Practice. 7th ed. Philadelphia, PA: Mosby Elsevier; 2008:chap 64.

7. Hernandez-Trujillo V, Mitchell G, Lieberman P. Allergy. In: Rakel RE, ed. Textbook of Family Medicine. 8th ed. Philadelphia, PA: Saunders Elsevier; 2011:chap 20.


http://emedicine.medscape.com/article/1191467-medication

http://www.nlm.nih.gov/medlineplus/ency/article/001390.htm

http://en.wikipedia.org/wiki/Vernal_keratoconjunctivitis

Education

Vernal conjunctivitis