Systematic approach to managing vernal keratoconjunctivitis in clinical practice: Severity grading system and a treatment algorithm

Nikhil S Gokhale, Nikhil S Gokhale

Abstract

Vernal keratoconjunctivitis is an ocular allergy that is common in the pediatric age group. It is often chronic, severe, and nonresponsive to the available treatment options. Management of these children is difficult and often a dilemma for the practitioner. There is a need to simplify and standardize its management. To achieve this goal, we require a grading system to judge the severity of inflammation and an algorithm to select the appropriate medications. This article provides a simple and practically useful grading system and a stepladder algorithm for systematic treatment of these patients. Use of appropriate treatment modalities can reduce treatment and disease-related complications.

References

    1. Ono SJ, Abelson MB. Allergic conjunctivitis: Update on pathophysiology and prospects for future treatment. J Allergy Clin Immunol. 2005;115:118–22.
    1. Katelaris CH. Ocular allergy in the Asia Pacific region. Asia Pac Allergy. 2011;1:108–14.
    1. Saboo US, Jain M, Reddy JC, Sangwan VS. Demographic and clinical profile of vernal keratoconjunctivitis at a tertiary eye care center in India. Indian J Ophthalmol. 2013;61:486–9.
    1. Sacchetti M, Lambiase A, Mantelli F, Deligianni V, Leonardi A, Bonini S. Tailored approach to the treatment of vernal keratoconjunctivitis. Ophthalmology. 2010;117:1294–9.
    1. Gokhale NS, Samant R, Sharma V. Oral cyclosporine therapy for refractory severe vernal keratoconjunctivitis. Indian J Ophthalmol. 2012;60:220–3.
    1. Williams PB, Sheppard JD., Jr Omalizumab: A future innovation for treatment of severe ocular allergy? Expert Opin Biol Ther. 2005;5:1603–9.
    1. Derriman L, Nguyen DQ, Ramanan AV, Dick AD, Tole DM. Intravenous immunoglobulin (IVIg) in the management of severe refractory vernal keratoconjunctivitis. Br J Ophthalmol. 2010;94:667–9.
    1. Leonardi A. Emerging drugs for ocular allergy. Expert Opin Emerg Drugs. 2005;10:505–20.
    1. Leonardi A, Borghesan F, DePaoli M, Plebani M, Secchi AG. Procollagens and inflammatory cytokine concentrations in tarsal and limbal vernal keratoconjunctivitis. Exp Eye Res. 1998;67:105–12.
    1. Tesse R, Spadavecchia L, Fanelli P, Rizzo G, Procoli U, Brunetti L, et al. Treatment of severe vernal keratoconjunctivitis with 1% topical cyclosporine in an Italian cohort of 197 children. Pediatr Allergy Immunol. 2010;21(2 Pt 1):330–5.
    1. Keklikci U, Soker SI, Sakalar YB, Unlu K, Ozekinci S, Tunik S. Efficacy of topical cyclosporin A 0.05% in conjunctival impression cytology specimens and clinical findings of severe vernal keratoconjunctivitis in children. Jpn J Ophthalmol. 2008;52:357–62.
    1. Kiliç A, Gürler B. Topical 2% cyclosporine A in preservative-free artificial tears for the treatment of vernal keratoconjunctivitis. Can J Ophthalmol. 2006;41:693–8.
    1. Pucci N, Caputo R, Mori F, De Libero C, Di Grande L, Massai C, et al. Long-term safety and efficacy of topical cyclosporine in 156 children with vernal keratoconjunctivitis. Int J Immunopathol Pharmacol. 2010;23:865–71.
    1. Fiscella RG, Le H, Lam TT, Labib S. Stability of cyclosporine 1% in artificial tears. J Ocul Pharmacol Ther. 1996;12:1–4.
    1. Schreiber SL, Crabtree GR. The mechanism of action of cyclosporin A and FK506. Immunol Today. 1992;13:136–42.
    1. Joseph MA, Kaufman HE, Insler M. Topical tacrolimus ointment for treatment of refractory anterior segment inflammatory disorders. Cornea. 2005;24:417–20.
    1. Pacharn P, Visitsunthorn N, Jirapongsananuruk O, Vichyanond P. Vernal Keratoconjunctivitis (VKC) treated with 0.1% FK-506 ophthalmic ointment: Result of three years follow-up. J Allergy Clin Immunol. 2007;119:S153.
    1. Labcharoenwongs P, Jirapongsananuruk O, Visitsunthorn N, Kosrirukvongs P, Saengin P, Vichyanond P. A double-masked comparison of 0.1% tacrolimus ointment and 2% cyclosporine eye drops in the treatment of vernal keratoconjunctivitis in children. Asian Pac J Allergy Immunol. 2012;30:177–84.
    1. Ring J, Möhrenschlager M, Henkel V. The US FDA 'black box' warning for topical calcineurin inhibitors: An ongoing controversy. Drug Saf. 2008;31:185–98.

Source: PubMed

3
Tilaa