Vernal keratoconjunctivitis (VKC)
David Kinshuck
Vernal keratoconjunctivitis VKC
In this condition the surface of the eye becomes red and sore and inflamed. This is a type of allergic eye disease, and is similar to atopic keratoconjunctivitis and giant papillary conjunctivitis. The immune system becomes overactive; a type 2 hypersensitivity reaction. The cause is not known, but it is partly genetic. There are environmental factors we partly understand, and these are discussed below.
The condition affects the conjunctiva, the cornea, and the conjunctiva under the eyelids.
enlarge the anatomy
enlarge some of the problems
The conjunctiva (the skin covering the eye) can develop tiny lumps, limbitis. In addition, and the under surface of the upper lid also becomes inflamed. The eye is very red and itchy to start with. When the condition is very active, it is very hard to open the eyes.
VKC can start as a child, young adult or adult, and can continue for many years. It usually starts about age 8y, and is worse in spring and summer, and stops in the late teens in 95% of patients. If the condition is not treated, the eye becomes very dry, and corneal scarring can reduce the sight. Corneal ulcers can develop, and later also scars. Later and the cornea and the undersurface of the upper lid can become scarred. Patients may also have asthma and eczema.
It is commoner in people with Southern Asian or North African ethnicity, and Equatorial areas. There is often atopic dermatitis around the eye, with fissuring and ptosis, and giant papillae.
There may be eczema, pigment , fissuirng, gpc, trantas dots. If there is mucous, the condtion is active. There will be granular mucous lissamine green stining; if multiple debdrites..hsv may be present. There may be small plaques
Shield ulcers and giant papillae
enlarge, shield ulcers on the cornea (shown in green)
- Shield ulcers may develop. These are sterile ulcers on the surface of the cornea.
- These sometimes need debriding under anaesthetic (children), with steroid injections in the upper lid.
enlarge: Giant papillae under the lid
- Giant papillae under the lid may develop, and these are treated with the standard medical treatment initially.
Symptoms
- itch, watering, discomfort, mucous discharge
- later reduced sight from scarring and cataract etc
- eye drops and wind may make the eye feel more sore
Medical treatment
This page outlines different treatments. If the condition is severe, advice from an ophthalmologist is essential. Anyone with sore eyes should ideally not use more than 4 eye drops a day containing preservative; if more drops are needed, they should be preservative free.
Extremely mild
Eye drops containing antihistamines, olopatadine (or if unavailable) ketotifen can be used for allergic conjunctivitis.BNF 20
More severe/flare ups
Loratidine (a systemic antihistamine) will help VKC, not ideal if it causes too much sedation
steroid such as
- dexamethasone drops 4 times a day 3-7 days
- dexamethasone drops 3 times a day 3-7 days
- dexamethasone drops 2 times a day 3-7 days
- dexamethasone drops 1 times a day 3-7 days
- measure eye pressure if possible as this may go up
More chronic
- If the condition recurs as the steroid dose is reduced, extra treatment is needed; add Cyclosporine Verkazia 1 mg/ml eye drops, 4 times a day in children or Ikervis in adults
- "The recommended dose is one drop of Verkazia 4 times a day (morning, noon, afternoon and evening) to be applied to each affected eye during the VKC season. If signs and symptoms of VKC persist after the end of the season, the treatment can be maintained at the recommended dose or decreased to one drop twice daily once adequate control of signs and symptoms is achieved. Treatment should be discontinued after signs and symptoms are resolved, and reinitiated upon their recurrence."
- As the Verkazia starts to work, the dose of steroid drops can be reduced.
- Protopic Protopic (tacrolimus 0.03%) on lids ...some must go in eye, twice a day . This is more more effective than Ikervis
Treat lids if there is an infection
Bactroban 2% cream (Mupirocin) to eyelid margin for lids is needed occasionally.
Preservative free lubricants
These are make the surface of the eye smooth. For mild disease Viscotears or Xailin gel 4 times a day may help. Xailin night may help at night. Some patients attending hospital will need lubricant drops, but these are usually not essential if a child dislikes drops etc.
- Hyloforte, Hyabak, Clinitas (sodium hyaluronate 0.4% preservative-free) every 4 hourly (can be increase in children with irritable eyes happier to use more drops), (alternatives include Visuxl, Thealoz duo)
- VitApos night
Steroid drops for more severe problems
Mild disease may respond to FML 3 times a day, reducing the dose over a few weeks. FML is a weak steroid, but is not ideal for continued use (see paragraph below).
Most hospital patients will need steroid eye drops, and these should be preservative free, such as dexamethasone preservative free e.g. Dropadex. They should not be used without an ophthalmologist's advice, unless your GP is experienced in their use and you only use them for short periods.
They have side effects, such as increasing the eye pressure, (causing glaucoma) and cataracts (which may need surgery later). Even short term use of steroid drops can activate herpes simplex keratitis.
If the eyes are red and sore and itchy, start 4 times a day. As soon as the redness fades, usually about 4 days, start to reduce the dose of the steroid to 3 and then twice a day. Once the redness has faded, continue for a few more days and then try to stop them.
If the redness and itch returns every time you stop, and as advised by
your ophthalmologist, you may need to use a low dose regularly, such
as once a day, and later alternate day use, or every third day etc, and then stopping.
Steroid drops have many side effects if used in the wrong manner. You
need to be certain that you do have 'allergic conjunctivitis' and not
another condition, and most people can recognise when their eyes are
red and itchy the condition has returned.
If there is scratchy and painful eye, you may have an ulcer and the drops should be stopped and expert advice is needed.
Protopic/Tacrolimus ointment (and Cyclosporine)
If the Cyclosporine Verkazia 1 mg/ml eye drops, is not effective, Tacrolimus ointment 0.03 % twice day (Protopic) to skin around eye cream twice takes a few weeks to work, so it should be started whilst the patient is using the steroid drops, with a maximum effect at 6 months, although there should be a definite improvement after 4 weeks. Some of the Protopic ointment should be allowed to enter the eye (otherwise there will be no effect on the conjunctiva).
Once the Protopic is working, the dose of the steroid drops can be reduced and may be stopped or continued at a low dose (reducing from 4 times a day to once a day or less often perhaps). When the Protopic is started it stings for a few days, but the stinging effect wears off. see see tacrolimus
Use cyclosporine and tacrolimus in combination, especially if steroids contraindicated. Eye 21
Plaque
...excise
Extremely severe
Pulsed methylprednisolone and long term immunosuppression and newer treatments.
Differential diagnosis
This includes
- Vkc or akc
- blepharokeratoconjunctivitis (rosacea..which is a chronic inflammation)
- pemphigoid
General measures
Dust allergy : precautions
People with allergic eye disease may be sensitive to dust, and the measures below may help. (This includes a few patients with AKC, but the advice just here is mainly for patients with mild allergic conjunctivitis.)
If you have a dust allergy there is plenty you can do. Visit the websites below for more details. This page has many details....although written for asthma patients, advice may be helpful.
- Try a new pillow or ultra-clean
towel over your pillow in bed. This might be particularly helpful
if you have your conjunctivitis at night or when you wake up. Any
regular pillow collects dust inside that after a while, and you
can become allergic to it. If this helps buy a non-allergenic pillow
with a special outer cover. After 5 years most pillows are 50% dust
mite!
Similarly, sleep on an ultra-clean towel, and if this helps buy special mattress and duvet covers. These can be expensive but can be very, very, helpful. - The dust mite is killed by freezing. Therefore, putting your pillow in the freezer for a few hours will kill all the mites. Try this, and if it helps it confirms you are allergic to dust. The dust mites accumulate, so you may need to repeat this every month. It may also help if you can put your mattress cover in the freezer, and your duvet and duvet cover, if they fit.
- Washing bedding at high temperatures also kills the dust mite.
- When hoovering..try to get someone else to do it...but if you cannot, try to dampen the floor first with a spray of water. When dusting, use a damp cloth.
- Keep your rooms ventilated, and perhaps turn the heating down, especially when you are out. The dust mite (which is what people are allergic to) likes centrally heated non-ventilated rooms.
- New carpets, or some people say wooden floors, help some people. Some people are allergic to their old sofa (any excuse for a new one, and a leather sofa is less allergenic). The current evidence concerning wooden floors is that they generally do not make all that much difference.
- To diagnose your dust allergy,
a trip abroad can be helpful! If you are allergic to the dust in your
home a trip to the Bahamas can make you feel much better!
If your allergy returns as soon as you come back, you have made the diagnosis, but the solution is more complex!
Lifestyle issues and Mediterranean diet
Lifestyle issues are critically important for patients with AKC
- Pollution aggravates allergies, so the less we all cause, the less others will suffer. The cleaner the air the better, so a beach holiday can be very helpful. Pollution in cities significantly increases allergies. Diesel pollution is harmful.
- An interesting paper pointed out that pro-biotics can reduce allergy rates This is a controversial area...partly because there are many different formulations. Nevertheless, they have no side effects and can be bought in health food shops.
- Generally a healthy diet is important. Fruits, vegetables, fish and the Mediterranean diet helps.
- A damp home certainly makes matters worse.
- Indoor chemicals increases allergies, a controversial area. No Yes. This author suggests that no chemicals are used in the home such as aerosols and cleaners, especially where ventilation is poor.
- Physical exercise reduces allergy rates
- Smoking in the home is very harmful. Smoking 20 cigarettes a day will probably increase allergies by 400%, that is 20% increase for each cigarette smoked. Electronic cigarettes are likely to be much much safer.
- living on a farm...fewer allergies
- low levels of Vitamin D are related to allergic eye disease (vitamin D is produced when sunlight hits our skin) 2016 2017 It contributes to related conditions: asthma asthma asthma rheumatoid arthritis
- Obesity probably increases autoimmune disease CMLS16 Increasing asthma asthma psoriasis rheumatoid arthritis.
Summarising: stepwise treatment of allergic conjunctivitis, including children
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VKC or AKC?
- VKC can start as a child, young adult or adult, and can continue for many years. It usually starts about age 8y, and is worse in spring and summer, and stops in the late teens.
- AKC develops in adulthood.
- VKC much commoner in tropics
- VKC males, young teens, south Asian and north African,
- AKC older
- AKC ..entropion etc
- AKC giant pap but then scars and featureless but still active
- AKC lower half of cornea affected
- VKC 95% remission
- VKC squamous cell ca in Africa
- VKC giant papillae, trantas dots, fissuring and pigment and ptosis..
- Cornea...VKC superior of cornea affected
- Vascularisation both AKC and VKC, VKC superior, inferior AKC
- There may be a corneal plaque, and the inflammation should be controlled before plaque removal.
- Chronic allergic conjunctivitis is linked to keratoconus and hydrops.
- both
- linked to eczema and asthma.
- Infection, secondary
- herpes simplex may occur
- Cataracts
- Treat: Olapatidine, antihistamines, tacrolimus, (cyclosporine is less effective), pulsed steroid, systemic
- Lid Protopic
- bactroban is preferred antibiotic,
- shield ulcers. Once inflammation controlled, remove plaque subconjunctival and injection with steroid,
- AKC.. doxycycline
Links
- for general and contact lens advice www.contactlenses.co.uk
- a link for professionals/interested patients for more information here
- for allergy avoidance (see this page on asthma)
- severe atopic lid disease, tacrolimus or Cyclosporine.
- vernal eye disease in Palestinians
- for a basic leaflet http://familydoctor.org/handouts/678.html
- buying anti-allergenic sheets, here is one company I found westonshealth.co.uk
- see Allergic Rhinitis in Children (BMJ)
- Pollution
in the air increases allergy rates considerably.
Our driving makes matters much worse.