Professional Documents
Culture Documents
Treatment of VKC - NOTES
Treatment of VKC - NOTES
1. NONPHARMACOLOGIC TREATMENT
2. PHARMACOLOGIC TREATMENT
3. SURGERY TREATMENT
1
Grade Symptoms Conj. Conj. Papillae Trantas dot Corneal
hyperemia secretion reaction involvement
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
3
Different therapeutic approach proposed for
the different vernal keratoconjunctivitis grades
Bonini, Stefano, et al. "Clinical grading of vernal keratoconjunctivitis." Current opinion in allergy and
clinical immunology 7.5 (2007): 436-441. 4
Treatment of vkc
Nonpharmacologic treatment
Avoiding allergens.
1. Patient education Avoid eye rubbing release mast cells
mediators, worsen itching, inlfammation
1) ANTI-HISTAMINS
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.
Jun, Jason, Leonard Bielory, and Michael B. Raizman. "Vernal conjunctivitis."Immunology and allergy clinics of
North America 28.1 (2008): 59-82.
6
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
7
MAST CELL STABILIZERS - Mainstay of therapy for VKC
Limit the flux of Calcium across mast cell membrane preventing degranulation.
9
Bielory, Leonard. "Ocular allergy treatment." Immunology and allergy clinics of North
America 28.1 (2008): 189-224.
10
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)
Bielory, Leonard. "Ocular allergy treatment." Immunology and allergy clinics of North America 28.1 (2008): 189-
224.
11
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.
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. 12
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.
therapeutic role)
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. 13
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
14
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.
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.
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. 15
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).
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.
Jun, Jason, Leonard Bielory, and Michael B. Raizman. "Vernal conjunctivitis."Immunology and allergy clinics of North America 28.1
(2008): 59-82.
17
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