TREATMENT OF VKC

1. NONPHARMACOLOGIC TREATMENT

2. PHARMACOLOGIC TREATMENT

3. SURGERY TREATMENT

1
Grade Symptoms Conj. Conj. Papillae Trantas dot Corneal
hyperemia secretion reaction involvement

0 (-) (-)/1+ (-) 1+/2+ (-) (-)

1 – Mild 1+/2+
intermittent 1+ 1+ (-)/1+ (-) (-)

2A – Moderate
intermittent 1+/2+ 1+ 1+ 1+/3+ (-) (-)
intermittent
2B - Moderate
persistant 1+/2+ 1+/3+
persistant 1+/2+ 1+/2+ (-) ± SPK

3 - Severe 2+/3+
2+/3+ ± few trantas
2+/3+ 2+/3+ Injection, SPK
persistant dots
swelling
4 – Very severe 2+/3+ Corneal
3+ 3+ 3+ Injection, ± numerous erosion/
persistant trantas dots
swelling ulceration
5 - Evolution
1+/3+
(-)/ 1+ (-)/1+ (-) (-) (-)
FIBROSIS

(-) absent ; 1+ mild; 2+ moderate; 3+ severe 2

Bonini, Stefano, et al. "Clinical grading of vernal keratoconjunctivitis." Current opinion in allergy and
clinical immunology 7.5 (2007): 436-441.
Clinical grading of VKC

Bonini, Stefano, et al. "Clinical

grading of vernal
keratoconjunctivitis." Current
opinion in allergy and clinical
immunology 7.5 (2007): 436-441.

3
Different therapeutic approach proposed for
the different vernal keratoconjunctivitis grades

4
Bonini, Stefano, et al. "Clinical grading of vernal keratoconjunctivitis." Current opinion in allergy and
clinical immunology 7.5 (2007): 436-441.
 TREATMENT OF VKC
Nonpharmacologic treatment

Avoiding allergens.
1. Patient education Avoid eye rubbing release mast cells
mediators, worsen itching, inlfammation

2. Cold compresses Symptomatic relief, esp. ocular itching

3. Lubrication/artificial Helps remove and dilute allergens.

Use preservative-free product to avoid toxic or
tears allergic reaction to preseratives.

Can protect cornea from mechanical friction of

giant tarsal papillae.
4. Soft contact lens But increase susceptibility to infection in pts
using topical corticosteroids.
5

Bielory, Leonard. "Ocular allergy treatment." Immunology and allergy clinics of North

America 28.1 (2008): 189-224.
 TREATMENT OF VKC
PHARMACOLOGIC TREATMENT

1) ANTI-HISTAMINS

2) MAST CELL STABILIZERS

3) NSAIDS

4) CORTICOSTEROIDS

5) IMMUNOSUPRESSIVE AGENTS

Bielory, Leonard. "Ocular allergy treatment." Immunology and allergy clinics of North America 28.1 (2008): 189-
224.
Kumar, Sunil. "Vernal keratoconjunctivitis: a major review." Acta ophthalmologica 87.2 (2009): 133-147. 6
Jun, Jason, Leonard Bielory, and Michael B. Raizman. "Vernal conjunctivitis."Immunology and allergy clinics of
North America 28.1 (2008): 59-82.
 ANTI-HISTAMINS
Rapid onset action
Vasocontricor Reduce itching + redness
antihistamin Naphazoline/pheniramine Side effects: tachyphylaxis,
combinations mydriasis, irritation,
hypersensitivity
1st generation:
Chlorpheniramine Reduce itching + conj.
Systemic Pheniramine Injection
antihistamin Pyrilamine
(Anti-H1) 2 generation:
nd
Can impair ocular tear film
Cetirizin (Cezil)
Loratadine  worsen allergic symptoms.
Fexofenodine (Telfast)
Rapid onset of action
Topical Levocabastine (0.05%) But short duration of action
antihistamin
(H1 receptor Emedasitne (0.05%)
Relief itching
blocker) (Emadine) Relief of signs/symptoms

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 MAST CELL STABILIZERS - Mainstay of therapy for VKC
Limit the flux of Calcium across mast cell membrane  preventing degranulation.

•Decrease discharge, photophobia, hyperemia,

edema of eyelid.
Cromoglycate: Do not decrease ECP tear.
Cromolyn 4% •
•Has no effect on papillary hypertrophy. Long term use
•Apply: 4-6 times/daily
Low onset of
action
Lodoxamide •Significant reduce ECP tear levels. (2-5 days after
0,1% •Reduce eosinophil infiltration and activation . initial using)
•Apply: 4 times/daily
Prophylatic
dosing
Pemirolast •Significant decrease histamin level.
0,1% •Reduce eosinophil infiltration and activation
(Alegysal) •Potency 100 times > Cromoglycate
•Apply: 4 times/daily
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ECP – eosinophil cationic protein,

 DUAL – ACTION (antihistamin and mast cell stabilizers)

Olopatadine Mast cell stabilizing effect

(Patanol, 0,1% H1 receptor binding
*Pataday 0,2%) Inhibit cytokines secretion
Rapid onset
Long duration of
action
Ketofiten (0,025%) No serious side
(Zaditor) Mast cell stabilizing effect
H1 receotor binding effect
Inhibit cytokines secretion
Nedocromil 2% Reduce eosinophils and Use b.i.d
neutrophils
Azelastine *Except:
Pataday 0,2%
Mast cell stabilizing effect Use once a day
Epinastine H1 – H2 receptor binding
(Elestat, Relestat) Inhibit cytokines secretion
Reduce eosinphils and neutrophils
9
 10
Bielory, Leonard. "Ocular allergy treatment." Immunology and allergy clinics of North
America 28.1 (2008): 189-224.
 TREATMENT OF VKC

Topical NSAIDS
Ketorolac
(Acular) Reduce itching and conj. injection by
inhibiting the systhesis of prostaglandins
Diclofenac
(Voltaren)
Papillary size and corneal lesions remain
unchange.
Flurbiprofen
(Ocufen)

11
Bielory, Leonard. "Ocular allergy treatment." Immunology and allergy clinics of North America 28.1 (2008): 189-
224.
 TREATMENT OF VKC - CORTICOSTEROID
 Corticosteroids can block most inflammatory pathways in the allergic
reaction, esp. late phase mediators.
Used over short periods (up to 2 weeks) – then taper.
Complications of long term use: cataracts formation (14%), increase IOP
(2-7%), secondary infection.

Indication in VKC:
(1) Moderate to severe case that are unresponsive to mast
cell stabilizers and antihistamines.
(2) Corneal involvement at any stage.

Bielory, Leonard. "Ocular allergy treatment." Immunology and allergy clinics of North America 28.1 (2008): 189-224.
12
Kumar, Sunil. "Vernal keratoconjunctivitis: a major review." Acta ophthalmologica 87.2 (2009): 133-147.
Jun, Jason, Leonard Bielory, and Michael B. Raizman. "Vernal conjunctivitis."Immunology and allergy clinics of North America 28.1
(2008): 59-82.
 TREATMENT OF VKC - CORTICOSTEROID
(1) ABSENCE of corneal involvement:
 1st line therapy: fluorometholone, loteprednol , rimexolone
 2nd line therapy : prednisolone, dexamethasone, betamethason

(2) ACTIVE corneal signs: initial use of PREDNISOLONE (even the

mildest forms of corneal disease)
 Dose and frequency: based on level of inflammation with gradual taper
occurring over 2 weeks.

2 types of corticosteroid use in ocular treatment:

 Keton corticosteroids (Keton group at C-20 position associated with cataract
formation): prednisolone, dexamethsone
 Ester corticosteroids (Ester group at C-20 position): loteprednol
 High lipophilicity  enhancing penetration into target inflammation.

 Not change IOP (rapid conversion to inactive metabolites after achieving

therapeutic role)
13
Bielory, Leonard. "Ocular allergy treatment." Immunology and allergy clinics of North America 28.1 (2008): 189-224.
Jun, Jason, Leonard Bielory, and Michael B. Raizman. "Vernal conjunctivitis."Immunology and allergy clinics of North America 28.1
(2008): 59-82.
TREATMENT OF VKC
 Supratarsal injection of corticosteroids: when topical
steroids are not effective or when a longer duration of
therapeutic effect is desired
 Temporary supression of inflammation in VKC
 0.5 – 1mm above superior tarsal border in the space
between conjunctiva and Muller muscle

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 TREATMENT OF VKC - Topical Cyclosporin A
(CsA)
 Mechanism:
 Blocks Th2 cells proliferaiton and IL2 production.
 Reduce IL5 production --> limit infiltration of eosinophil
 inhibits histamine release from mast cells and basophils.

 Not associated with: lens changes or increase IOP

 Side effects: burning and itching

BUT: Dose and frequency: ??

 Cyclosporin 1% - 2% (in olive or castor oil): show effect in
treatment VKC
 But commercial available: Cyclosporine 0,05% (Restasis).

Bielory, Leonard. "Ocular allergy treatment." Immunology and allergy clinics of North America 28.1 (2008): 189-224.
Jun, Jason, Leonard Bielory, and Michael B. Raizman. "Vernal conjunctivitis."Immunology and allergy clinics of North America 28.1
15
(2008): 59-82.
Spadavecchia L, Fanelli P, Tesse R et al. (2006): Efficacy of 1.25% and 1% topical cyclosporine in the treatment of severe vernal
keratoconjunctivitis in childhood. Pediatr Allergy Immunol 17: 527–532.
 TREATMENT OF VKC - Topical Cyclosporin A
(CsA)

 Topical CsA helps healing shield ulcers  But recurrences may

occur at lower concentrations (Cetinkaya et al. 2004).

 Off-label use of topical CsA (0.05%) decreased the symptoms

and signs of VKC (Ozcan et al. 2007).

 Topical corticosteroids + artificial tears + topical CsA (0.05%) 

help in the re-epithelialization of corticosteroid-resistant
vernal shield ulcers (Kumar 2008).

16
Kumar, Sunil. "Vernal keratoconjunctivitis: a major review." Acta ophthalmologica 87.2
(2009): 133-147.
 TREATMENT OF VKC - Tacrolimus
Tacrolimus (Ophthalmic ointment 0,1%)

Prevent activation and proliferation of lymphocytes and

other immune cells (Suppresses T-cell activation, Th cells
response, B-cells proliferation)
Inhibit cytokines release (esp. IL2)

Bielory, Leonard. "Ocular allergy treatment." Immunology and allergy clinics of North America 28.1 (2008): 189-224.
Kumar, Sunil. "Vernal keratoconjunctivitis: a major review." Acta ophthalmologica 87.2 (2009): 133-147. 17
Jun, Jason, Leonard Bielory, and Michael B. Raizman. "Vernal conjunctivitis."Immunology and allergy clinics of North America 28.1
(2008): 59-82.
TREATMENT OF VKC - Surgical treatment
Surgical excision of giant papillae : if cause corneal lesions.
 Helps in resolution of corneal epitheliopathy or ulcer
 BUT papillae regrow in most pts.
• Excision
• Cryocoagulation
• Co2 laser

Cryotherapy of giant papillae  +/- conjunctival scarring.

Intraoperative application of 0.02% MMC 2 min/upper palpebral

conjunctiva  reduces the chances of recurrence of papillae
significantly.
18
Kumar, Sunil. "Vernal keratoconjunctivitis: a major review." Acta
ophthalmologica 87.2 (2009): 133-147.