Active Vernal Keratoconjunctivitis Research Articles

Clinical Outcomes of Topical 0.1% Ciclosporin Cationic Emulsion Used on Label in Children with Vernal Keratoconjunctivitis.

The purpose of this short article is to report the clinical outcomes of topical 0.1% ciclosporin cationic emulsion (CsA-CE) used on label in children with vernal keratoconjunctivitis (VKC). In this prospective, non-comparative, observational study children affected by active severe VKC were treated for at least 12months with topical 0.1% CsA-CE. The drug was instilled in both eyes 4 times daily. Data collected from medical charts for the baseline visit (T0) and 1-year follow-up visit (T1) included symptomatic score (0-15), clinical score (0-15), side effects, rescue therapy (need and total number of courses with 0.1% dexamethasone 4times daily for 5days), ocular complications and tolerability (visual analog scale [0-100]). Data from 25 children (20 boys, 5 girls; mean [± standard deviation] age 8.40 ± 2.54 years) were included in the study. Of the 25 patients, 23 (92%) used 0.1% CsA-CE eye drops as per label recommendations, including four patients who had prematurely stopped using topical galenic CsA due to side effects. Symptomatic and clinical scores decreased significantly after treatment, with the mean symptomatic score decreasing from 9.76 ± 1.27 at T0 to 3.80 ± 1.08 at T1, and the mean clinical score decreasing from 9.20 ± 1.32 at T0 to 3.44 ± 1.00 at T1; both P < 0.0001). Five patients (20%) required at least one course of rescue medication (mean 3.4 ± 4.8 courses/year). No patients experienced ocular complications during the study, and treatment tolerability was very high (mean score 89.40 ± 5.46). Our findings confirm that topical CsA-CE is an effective on-label option for children with VKC in the real-life setting. In our pediatric patient population, CsA-CE provided good clinical outcomes with a limited need for rescue medication, and it was well tolerated by almost all patients, including those who were intolerant to galenic formulations.

Anterior-segment optical coherence tomography for tacrolimus therapy response monitoring of vernal keratoconjunctivitis

Background: Vernal keratoconjunctivitis (VKC), a chronic bilateral eye disease, is a severe form of allergic conjunctivitis. Anterior-segment optical coherence tomography (AS-OCT) is a rapid, noninvasive, in vivo visualization modality for the anterior segment structures that has been used in diagnosing and staging diseases and assessing the treatment efficacy. We used anterior-segment optical coherence tomography (AS-OCT) to monitor the efficacy of the tacrolimus eye ointment in managing VKC.&#x0D; Methods: In this prospective follow-up study, we included patients with active symptomatic VKC. All patients were treated with the 0.03% tacrolimus ophthalmic ointment twice daily for 2 months and then once daily for 1 month. All patients underwent AS-OCT before and 3 months after treatment as an objective method to assess the treatment efficacy.&#x0D; Results: We included 20 eyes of ten patients (nine men and one woman) with active symptomatic VKC. The mean age was 17.3 (range: 11 – 36) years, with nine patients having a palpebral type and one patient having a mixed type of VKC. Substantial flattening and reduction in the papilla size were observed in all patients at the post-treatment follow-up. AS-OCT measurements revealed significant reductions in the vertical, horizontal, and total diameters of the palpebral papillae and limbal conjunctival thickness after 3 months of treatment compared to baseline measurements (all P &lt; 0.001). No serious adverse effects attributable to tacrolimus administration were observed in the study period.&#x0D; Conclusions: AS-OCT is a suitable objective method for evaluating the treatment efficacy of the 0.03% tacrolimus eye ointment in patients with VKC. Future large-scale studies including a wide range of age groups with longer follow-up periods and AS-OCT monitoring at multiple post-treatment visits are required to confirm our preliminary results. Moreover, the diagnostic accuracy of AS-OCT in monitoring patients with active VKC should be tested in comparison with objective scoring by an experienced corneal fellowship.

Clinical and demographic profile of vernal keratoconjunctivitis at a tertiary eye care hospital in national capital region of India

To study the clinical and demographic profile of patients with vernal keratoconjunctivitis (VKC) at a tertiary eye care center in NCR of India. A total of 92 patients with active VKC, were included in the study. Age, gender, personal and family allergies, presenting symptoms, duration of disease, complete ocular examination and complications were recorded. The Mean age at presentation was 9 years with male to female ratio of 3.4:1. Majority of the patients had mixed pattern disease (72.8%). Chronic perennial disease was seen in 44% patients. Personal or family history of allergies was noted in 9.8% patients. Moderate to severe vision loss was seen in 8.7% of cases. The commonest complication was peripheral corneal neovascularisation in 7.6% patients. VKC is the disease of childhood,and males are more commonly affected. In this region,mixed type and with perennial diseaseis the most common form.

Health-related quality of life in children at the diagnosis of Vernal Keratoconjunctivitis.

Vernal keratoconjunctivitis (VKC) is a bilateral, chronic, allergic condition mostly affecting children. Clinical evaluations may not necessarily reflect the impact of the disease on the patients' health-related quality of life (HRQoL). We aimed to evaluate HRQoL in children at VKC diagnosis and to analyze correlations between HRQoL and clinical and laboratory variables. We studied 5- to 12-year-old patients with VKC. Data on clinical history, instrumental eye evaluations, blood examinations, and visual analog scale (VAS) for the subjective symptoms were collected. HRQoL was assessed through a disease-specific validated Quality of Life in Children with Vernal Keratoconjunctivitis (QUICK) questionnaire. Seventy subjects were included in the analysis (female/male: 10/60; tarsal/mixed VKC form: 36/34). Clinical severity of VKC according to the Bonini scale was as follows: 14, mild; 36, moderate; and 20, severe. No significant difference was found concerning the distribution of patient age, gender, and history of allergic manifestations between tarsal and mixed VKC. A significant positive correlation was found between all QUICK scores and VAS scores, including different VAS subscale, while no significant correlation was found between QUICK scores and total sign scores, Schirmer's test, and corneal thickness. The presence of active severe VKC was not associated with worse HRQoL. Our evidence shows that VKC patients experience impairment of HRQoL, especially in relation to the perception of symptoms independently of the ophthalmologic changes found, and that the QUICK questionnaire could be a useful tool to evaluate HRQoL in children with VKC, which may improve patients' classification and management.

COMPARATIVE EVALUATION OF TACROLIMUS 0.03% OINTMENT VS OLOPATADINE 0.2% EYE DROPS IN THE TREATMENT OF VERNAL KERATOCONJUNCTIVITIS

Objective: To compare the efficacy of tacrolimus 0.03% ointment to olopatadine 0.2% eye drops in the treatment of vernal keratoconjunctivitis.&#x0D; Study Design: Prospective cross-sectional study.&#x0D; Place and Duration of Study: Eye Department Combined Military Hospital Quetta, from Feb to Jul 2019.&#x0D; Methodology: A total of 69 patients with active vernal keratoconjunctivitis (VKC) were included in this study.Thirty six (52.17%) patients were randomized in tacrolimus group and 33 (47.83%) in olopatadine group B.Baseline values of the subjective symptom score (SSS) and the objective sign score (OSS) were noted. Patientswere reviewed on weeks 2, 4, 8 and 12 and the scores at each visit were summed. These scores were used forcomparison between groups.&#x0D; Results: At the start of the study, the mean subjective symptoms score and objective sign score of group A was 9.0 ± 2.04 and 3.93 ± 1.93 respectively, while that of group B was 8.88 ± 2.18 and 4.36 ± 1.90 respectively. At the end of 12-weeks, the mean subjective symptoms score and objective sign score of group A reduced to 0.11 ± 0.32 and 0.08 ± 0.28 respectively, while that of group B reduced to 1.70 ± 0.77 and 0.64 ± 0.55 respectively. Total improvement of scores (as a percentage of baselines) among tacrolimus group was 98.3% and olopatadine group was 83%.&#x0D; Conclusion: Although both 0.03% tacrolimus and 0.2% olopatadine were effective in improving the signs andsymptoms of VKC, 0.03% tacrolimus was significantly superior.

Twelve-Month Results of Cyclosporine A Cationic Emulsion in a Randomized Study in Patients With Pediatric Vernal Keratoconjunctivitis

To assess the safety and efficacy of cyclosporine A cationic emulsion (CsA CE) 0.1% eye drops in pediatric patients with severe active vernal keratoconjunctivitis (VKC). Multicenter, double-masked, randomized controlled trial 8-month safety analysis. Of 169 patients (age range, 4-17 years) initially randomized in the 4-month VErnal KeratoconjunctiviTIs Study (VEKTIS), 142 entered the 8-month follow-up period during which CsA CE patients remained on their original regimen (CsA CE 4 times daily [QID, high-dose] or CsA CE twice daily [BID, low-dose]+ vehicle BID) and vehicle patients were allocated to one of these 2 active regimens. Main outcome measures were safety, including treatment-emergent adverse events, and efficacy, including corneal fluorescein staining (CFS) score. Improvements in CFS score, rescue medication use, key VKC symptoms (photophobia, tearing, itching, and mucous discharge), and quality of life (QoL) assessed by QUICK questionnaire observed with CsA CE compared with vehicle during the 4-month evaluation period remained stable during the 8-month follow-up period, with the high-dose regimen continuing to provide greater benefits in most efficacy measures. CsA CE was well tolerated. Treatment-related treatment-emergent adverse events during the 12-month study were reported in 15 (20.8%) and 11 (15.7%) of the CsA CE high-dose and low-dose patients, respectively, most commonly instillation site pain (13.9% and 7.1%, respectively). Laboratory data, vital signs, slit lamp examination, best-corrected distance visual acuity, and intraocular pressure raised no safety concerns. Improvements in keratitis, symptoms, and QoL achieved after CsA CE treatment for 4months remained stable over the 8-month follow-up period. CsA continued to maintain a favorable safety profile.

Vitamin D serum levels in children with vernal keratoconjunctivitis and disease control.

The aim of this study was to evaluate whether the control of ocular symptoms with cyclosporine or with tacrolimus in eye drops allows to improve sun exposure and therefore serum level of vitamin D (VD; 25OHD), in the more severe forms of vernal keratoconjunctivitis (VKC). Out of 242 children followed for active VKC, 94 were treated with 1% cyclosporine or 0.1% tacrolimus eye drops, while the other 148 with mild VKC did not need to be treated with immunomodulators. VD serum levels were measured in spring and autumn in 71 children. In total, 60 of them were treated with cyclosporine eye drops (first group) and 11 (not responding to cyclosporine therapy previously) with 0.1% tacrolimus eye drops (second group) between March and November 2016. Pre-treatment median values of VD were 23.7 ng/mL in the first group and 23.8 in the second group, and post-treatment values increased up to 32.8 and 32.9 ng/mL, respectively. Before treatment, 33% presented a deficiency (25OHD < 20 ng/mL), and at the end of summer, only 4% were deficient. The overweight children had lower improvement in VD serum levels than children with a body mass index (BMI) lower than 85th percentile. Children in therapy with cyclosporine, but requiring the administration of local steroid therapy during the summer for control of the symptoms, showed a greater improvement in 25OHD serum levels in ng/mL (23–37 ng/mL) than children who did not require steroid therapy (24–35 ng/mL). Furthermore, there was a significant difference in change of 25OHD in children presenting limbal VKC (21–41 ng/mL) versus tarsal VKC (24–35 ng/mL) (P = 0.04). Our study suggests that ocular treatment carried out with immunomodulator eye drops could allow for an improvement in 25OHD serum levels. In children with active VKC and at risk of 25OHD deficiency, likely due to avoidance of sun exposure, the role of other risk factors (BMI, phototype and treatment) on 25OHD serum levels should be considered.

A Randomized, Controlled Trial of Cyclosporine A Cationic Emulsion in Pediatric Vernal Keratoconjunctivitis: The VEKTIS Study

Vernal keratoconjunctivitis (VKC) is a chronic, allergic, and potentially severe ocular disease affecting children and adolescents that can lead to impaired quality of life (QoL) and loss of vision. This study evaluated the efficacy and safety of an investigational therapy for severe VKC, cyclosporine A (CsA) cationic emulsion (CE), an oil-in-water emulsion with increased bioavailability versus conventional CsA formulations. The VErnal KeratoconjunctiviTIs Study (VEKTIS) is a phase 3, multicenter, double-masked, vehicle-controlled trial. Pediatric patients (4 to younger than 18 years) with active severe VKC (grade of 3 or 4 on the Bonini severity scale) and severe keratitis (corneal fluorescein staining [CFS] score of 4 or 5 on the modified Oxford scale). One hundred sixty-nine patients were randomized to CsA CE 0.1% (1 mg/ml) eye drops 4 times daily (high dose), CsA CE twice daily (low dose) plus vehicle twice daily, or vehicle 4 times daily for 4 months. The primary end point was a mean composite score that reflected CFS, rescue medication use (dexamethasone 0.1% 4 times daily), and corneal ulceration over the 4 months. Differences in least-squares means versus vehicle for the primary end point were statistically significant for both the high-dose (0.76; P= 0.007) and the low-dose (0.67; P= 0.010) groups, with treatment effect mainly driven by CFS score. Significant differences were found between both active treatment groups and vehicle for use of rescue medication. Vernal keratoconjunctivitis symptoms and patient QoL (assessed by visual analog scale and the Quality of Life in Children with Vernal Keratoconjunctivitis questionnaire) improved in all 3 groups, with significant improvements for high-dose CsA CE versus vehicle. The efficacy of high-dose CsA CE in improving keratitis, symptoms, and QoL for those with severe VKC was demonstrated in these study patients. In addition, in this study cohort, CsA CE was well tolerated.

Sex hormones in allergic conjunctivitis: altered levels of circulating androgens and estrogens in children and adolescents with vernal keratoconjunctivitis.

Purpose. Vernal keratoconjunctivitis (VKC) is a chronic allergic disease mainly affecting boys in prepubertal age and usually recovering after puberty. To evaluate a possible role of sex hormones in VKC, serum levels of sex hormones in children and adolescents with VKC were assessed. Methods. 12 prepubertal and 7 early pubertal boys with active VKC and 6 male patients with VKC in remission phase at late pubertal age and 48 healthy age and sex-matched subjects were included. Serum concentration of estrone, 17 beta-estradiol, dehydroepiandrosterone-sulfate, total testosterone and free testosterone, dihydrotestosterone (DHT), cortisol, delta-4-androstenedione, follicle-stimulating hormone, luteinizing hormone, and sex-hormones binding globuline (SHBG) were evaluated. Results. Serum levels of Estrone were significantly increased in all groups of patients with VKC when compared to healthy controls (P < 0.001). Prepubertal and early pubertal VKC showed a significant decrease in DHT (P = 0.007 and P = 0.028, resp.) and SHBG (P = 0.01 and P = 0.002, resp.) when compared to controls and serum levels of SHBG were increased in late pubertal VKC in remission phase (P = 0.007). Conclusions and Relevance. VKC patients have different circulating sex hormone levels in different phases of the disease and when compared to nonallergic subjects. These findings suggest a role played by sex hormones in the pathogenesis and/or activity of VKC.

Tear Cytokine Levels in Vernal Keratoconjunctivitis

The aims of this study were to evaluate the efficacy of topical 0.05% cyclosporine A on clinical signs and symptoms of vernal keratoconjunctivitis (VKC) and to examine its effect on tear cytokine levels. Twenty-one patients with active VKC and 15 healthy volunteers were included. Patients were treated with topical 0.05% cyclosporine A. Symptoms and signs were scored on the day of enrollment and at the end of month 1 and month 3. Tear and serum samples were collected before and on the third month of treatment. Interleukin (IL)-2, soluble IL-2 receptor (sIL-2R), IL-3, IL-4, IL-5, IL-6, IL-9, IL-13, IL-17, eotaxin, tumor necrosis factor alpha (TNF-α), and interferon gamma (IFN-γ) in cell-free tear and serum supernatants were measured by multiplex bead analysis. At the end of month 1 and month 3 with topical 0.05% cyclosporine A treatment, statistically a significant decrease was observed in sign and symptom scores of the patients (P < 0.0001). Tear IL-2, sIL-2R, IL-9, IL-17, IFN-γ, and eotaxin levels in VKC patients were significantly higher than those in controls (P < 0.05). IL-3, IL-4, IL-5, and TNFα levels tended to be higher in VKC patients. There was also statistically significant reduction from before 0.05% cyclosporine A treatment to after treatment in tear levels of IL-4, IL-5, IL-17A, TNFα, IFN-γ, and eotaxin (P < 0.05). IL-2 and sIL-2R levels tended to be lower than pretreatment levels. Topical 0.05% cyclosporine A is effective in alleviating signs and symptoms of VKC patients and shows its effect probably by decreasing the local production of some inflammatory mediators in tears.

Identification of the 37kda Annexin-A1 Protein in Tears of Normal Subjects and Association of its 33kda Inactive Form with Active Vernal Keratoconjunctivitis Patients

Background: Annexin-A1 (Anx-A1) is a glucocorticoid-regulated 37kDa protein with powerful anti-inflammatory actions: enhanced release from target cells occurs following addition of the anti-allergic cromone drugs. Anx-A1 is inactivated by proteolytic cleavage of the N-terminus and increased amounts of the cleaved 33kDa product correlate with inflammatory responses. Aim: To investigate if Anx-A1 is detectable in human tear specimens from patients with vernal keratoconjunctivitis (VKC). Methods: Tear specimens were collected from patients affected by active VKC (n=23) before and after therapy with Alomide (equivalent to Lodoxamide) 0.1%(n=11) for 10 daysand non-inflammatory control tear specimens from healthy volunteers (n=17) who gave informed consent. Anx-A1 protein levels were measured by ELISA and by Western blotting. Results: In cell-free tear specimens from healthy donors, the concentration of Anx-A1 was 433.6 ± 54.3 pg/ ml (n=17) and >90% was in the intact form. In tears from VKC patients however, total Anx-A1 increased to 1908 ± 319.3pg/ml (n=23; p 80% is intact form, n=11, p<0.01). Conclusion: Anx-A1 is constitutively present in normal human tears and is proteolytically cleaved to inactivation during chronic allergic disease. Alomide treatment decreased the proportion of cleaved protein in VKC patients, and this is perhaps related to its therapeutic action.

The discordance between objective signs and giant papillae improvement in patients with vernal keratoconjunctivitis (VKC) participating in a randomized, controlled, clinical trial

AbstractPurpose Resolution of papillae is a desirable objective in the management of tarsal VKC. The effect of Vekacia®, an unpreserved cyclosporine cationic emulsion, was evaluated in children with active VKC presenting with giant papillae and keratitis at enrollment.Methods 118 VKC patients were randomized to Vekacia® 0.05%, 0.1%, or vehicle QID. The primary criterion was subjective symptom improvement. Objective signs (giant papillae, conjunctival hyperemia, discharge, chemosis, limbal infiltrates and corneal epithelial disease) were assessed as secondary endpoint.Results At Day 28, patient subjective symptoms improved in all groups without statistically significant difference between groups. Among the objective signs, except for papillae, clinically significant improvements were observed: absence of the sign ranged from 20.5% to 72% in both active groups and from 16.7% to 41.2% for vehicle group, depending of the sign. For papillae, only 4 patients experienced total clearing (2.8%, 2.6% and 6.6% in vehicle, 0.05% and 0.1% CsA groups respectively). Clinically and statistically significant differences in keratitis (CFS mean change) over vehicle were observed at Day 28 in Vekacia® treated patients (0.05%, p=0.003; 0.1% p=0.014).Conclusion Corneal involvement in VKC is a sight‐threatening complication. Improvement in keratitis, a key element in the management of the active VKC was not associated with complete resolution of the papillae. Therefore, among the signs of the disease, papillae appear to be the least helpful sign to follow VKC improvement. Commercial interest

Role of Cyclosporine Eye Drops In Allergic Conjunctivitis

Purpose: To evaluate the effects of topical 2% cyclosporin eye drops in patients with active vernal keratoconjunctivitis. Material and Methods: Thirty seven patients with active vernal keratoconjunctivitis diagnosed at least one year before and treated with a variety of topical medications except cyclosporin were included in the study. All patients were treated with 2% cyclosporin eye drops four times daily in both eyes for 6 weeks. Symptoms (itching, watering, photophobia, mucous discharge and foreign body sensation) and signs (conjunctival hyperemia, trantas’ dots, limbal oedema, epithelial punctate keratitis and palpebral conjunctival papillae) of vernal keratoconjunctivitis were recorded before treatment and at the end of treatment period. Results: There was a statistically significant improvement in itching, photophobia, mucous discharge, conjunctival hyperemia, punctate keratitis and trantas’ dots after 6 weeks treatment period. No significant adverse effect of treatment with topical cyclosporin was observed except for mild to moderate stinging and burning upon administration. Conclusion: Topical cyclosporin is an effective and safe agent in the treatment of vernal keratoconjunctivitis.

Cytokines, matrix metalloproteases, angiogenic and growth factors in tears of normal subjects and vernal keratoconjunctivitis patients

To detect the presence of multiple mediators and growth factors in tears of vernal keratoconjunctivitis (VKC) patients with active disease using stationary phase antibody arrays. Tears were collected from 12 normal subjects (CT) and 24 active VKC patients. Tears were centrifuged and successively probed using three microwell plate arrays specific for: (i) cytokines: interleukin (IL)-2, IL-4, IL-5, IL-8, IL-10, IL-12, IL-13, interferon-gamma and tumour necrosis factor-alpha; (ii) growth factors: basic fibroblast growth factor (bFGF), platelet-derived growth factor, thrombopoietin, angiopoietin-2, vascular endothelial growth factor (VEGF), hepatocyte growth factor (HGF), keratocyte growth factor, tissue inhibitor of metalloprotease (TIMP)-1 and heparin-binding epithelial growth factor (HB-EGF) and (iii) matrix metalloprotease (MMP)-1, MMP-2, MMP-3, MMP-8, MMP-9, MMP-10, MMP-13, TIMP-1 and TIMP-2. Interleukin-8 signals were detected in all CT and highly detected in all VKC samples. The Th2-type cytokines, IL-4, IL-5 and IL-10 were detected only in tears of VKC patients. Signals for bFGF, HB-EGF, VEGF and HGF were detected in 41-87% of VKC samples and in few CT samples. Only TIMP-1 and TIMP-2 were found in all normal and patient tear samples, whereas MMP-1, MMP-2, MMP-3, MMP-9 and MMP-10 were highly present in all VKC samples. Stationary phase antibody array methodology was useful for the screening of various cytokines, growth factors and MMPs in tears. These analyses identified in tears of VKC patients previously unreported factors including MMP-3 and MMP-10 and multiple proteases, growth factors and cytokines, which may all play an important role in the pathogenesis of conjunctival inflammation.

Development and Testing of the Quality of Life in Children with Vernal Keratoconjunctivitis Questionnaire

To develop and validate a questionnaire that measures health-related quality of life (HRQoL) in children with vernal keratoconjunctivitis (VKC). Prospective, observational case series. An initial list of 42 items was developed and administered to 30 children with active VKC (six girls and 24 boys; mean age, nine +/- two years). The 30 most significant items were selected and converted into questions on a three-step scale for validation in 41 children with active VKC (eight girls and 33 boys; mean age, 9.5 +/- 2.1 years). Twenty-two children also completed the generic KINDL questionnaire. Clinical signs were evaluated and scored and total sign scores (TSSs) were calculated. Validation was performed by factorial analysis and Pearson correlation. Internal consistency was computed by the Chronbach alpha on the extracted factors. Factorial analysis extracted two factors with good internal consistency: symptoms (12 items; alpha = 0.89) and daily activities (four items; alpha = 0.77). Correlations of Quality of Life in Children with Vernal Keratoconjunctivitis (QUICK) scores to KINDL scores were in the expected direction. Most patients reported itching (93%), burning (90%), redness (90%), the need to use eye drops (90%), tearing (83%), and photophobia (80%). The children's greatest concerns were limitations on going to the pool (71%), playing sports (58%), and meeting friends (58%). QUICK symptom scores were correlated significantly to conjunctival hyperemia (P < .001), secretion (P = .042), chemosis (P = .012), superficial punctate keratopathy (P < .001), and TSS (P = .010). The QUICK questionnaire is a new, simple instrument to measure HRQoL in children with severe allergic conjunctivitis. This test is effective for the global evaluation of the impact of VKC on children's daily lives.

Systematic review and meta-analysis of randomised clinical trials on topical treatments for vernal keratoconjunctivitis

Aims:The aim of this study was to assess the efficacy of currently available topical drugs for vernal keratoconjunctivitis (VKC) through a meta-analysis of randomised clinical trials (RCTs).Methods:Twenty-seven RCTs (n =...

Trypsin Inhibitory Capacity in Vernal Keratoconjunctivitis

To study tear trypsin inhibitory capacity (T-TIC), serum trypsin inhibitory capacity (S-TIC) and their relationship to matrix metalloproteinases (MMP)-1 and -9 in patients with vernal keratoconjunctivitis (VKC). In the first phase of the study, inactivation of alpha-1 antitrypsin (AAT) by MMP-1 and -9 was investigated in vitro. Subsequently, tear samples were collected after clinical evaluation from 14 patients with active VKC and 15 normal control subjects. Tear cytology was performed on all samples. Levels of T-TIC and S-TIC were determined by spectrophotometry, whereas levels of tear pro-MMP-1, pro-MMP-9, and active MMP-1 and -9 were determined by enzyme-linked immunosorbent assay (ELISA). MMP-1 and -9 inactivated AAT in vitro. S-TIC was significantly higher (P < 0.0001), and T-TIC (P < 0.0001) significantly lower in VKC samples. Tear levels of pro-MMP-1 and pro-MMP-9, and the activity of MMP-1 and -9 was significantly greater in patients with VKC than in healthy subjects (P < 0.0001). There was no significant correlation between T-TIC, MMP-1, and MMP-9 activity. In addition, T-TIC was not correlated to the total clinical score or to single clinical sign scores. In this study, tear trypsin inhibitory capacity was shown to be reduced and tear MMP-1 and -9 activity increased in patients with VKC. Although T-TIC did not correlate with VKC severity, a local reduced inhibitory capacity of ATT may facilitate or prolong conjunctival inflammation in VKC.

Th1- and Th2-type cytokines in chronic ocular allergy

Previous reports have suggested that Th2-type cytokines are important in the pathogenesis of ocular allergic diseases. The purpose of this study is to measure levels and mRNA expression of Th1- and Th2-type cytokines in patients with active vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC). Tear samples and tear-isolated cells were obtained from 9 healthy participants (CT--controls), 28 VKC, and 6 AKC patients. IL-4, IL-13, and interferon gamma (IFNgamma) tear levels were determined by ELISA, and IL-4 and IFNgamma tear cell mRNA expression by RT-PCR. Effects of these cytokines on IL-6 and IL-8 secretion, and on ICAM-1 expression by conjunctival fibroblasts, were evaluated by ELISA and flow cytometry respectively. Interleukin-4 tear levels were increased in VKC and AKC compared with CT, but only IFNgamma significantly correlated with corneal involvement. An IL-4/13-dominant profile was found in 50% of VKC and in 17% of AKC patients, while a IFNgamma-dominant profile was found in 18% of VKC and in 17% of AKC patients. IL-4 and IFNgamma transcripts were detected in tear cells from 11 out of 12 VKC patients. IFNgamma upregulated expression of ICAM-1 on conjunctival fibroblasts and the secretion of IL-6 and IL-8. Although both IL-4 and IFNgamma are detected in tears, only IFNgamma levels correlated with disease severity and upregulated ICAM-1 on conjunctival fibroblasts, suggesting the role of IFNgamma in the inflammatory phase of chronic allergic eye diseases.

Expression of Toll-like Receptors in Healthy and Allergic Conjunctiva

To investigate the expression of toll-like receptors (TLRs) in healthy and active vernal keratoconjunctivitis (VKC) conjunctiva. Comparative nonrandomized interventional study. Nine patients with vernal keratoconjunctivitis and 10 healthy subjects. Normal and VKC conjunctiva were evaluated for TLR-2, TLR-4, and TLR-9 mRNA and proteins by relative real-time polymerase chain reaction and immunohistochemistry. Colocalization of TLRs was further evaluated by confocal microscopy and double-labeled immunofluorescence in T cells (CD4), mast cells (AA1), and eosinophils (EG2). Identification of TLRs at molecular and biochemical levels and identification of inflammatory cells that coexpress these receptors. Toll-like receptor 2, TLR-4, and TLR-9 were expressed in normal and VKC conjunctival epithelium and stroma, both with a more intense immunoreactivity in the stroma. In VKC tissues, TLR-4 was upregulated, TLR-9 was downregulated, and TLR-2 was slightly decreased relative to normal tissues. Toll-like receptor 4 was localized on CD4+ lymphocytes, eosinophils, and mast cells, whereas lymphocytes and eosinophils, but not mast cells, expressed TLR-9. Toll-like receptors are expressed in healthy and allergic conjunctiva. The upregulation or downregulation of these receptors and their presence on inflammatory cells suggest a role of TLRs in VKC.

Urokinase Plasminogen Activator, uPa Receptor, and Its Inhibitor in Vernal Keratoconjunctivitis

Plasminogen activators play a role, not only in fibrinolysis but also in events such as chemotaxis, collagen degradation, and cell spreading. The serine protease urokinase (uPA) is a potent chemoattractant for leukocytes that may be involved in the pathogenesis of severe forms of allergic conjunctivitis such as vernal keratoconjunctivitis (VKC). Tear and peripheral blood samples were obtained from 20 patients with active VKC and from 19 normal subjects who formed the control group. Levels of plasminogen activity, uPA, tissue plasminogen activator (tPA), and their inhibitor, plasminogen activator inhibitor type-1 (PAI-1) were measured in tears and plasma of patients with VKC. The presence of tPA, uPA, and urokinase receptor (uPAR) in conjunctival tissues were evaluated by immunohistochemistry. uPA, uPAR, and PAI-1 expression and production were measured in conjunctival epithelial cell and fibroblast cultures treated with cytokines. Tear levels of uPA and tPA and tear plasminogen activity levels were significantly greater in patients with VKC than in control subjects. Increased staining for uPA and uPAR was found in VKC tissues compared with normal conjunctiva. Both conjunctival epithelial cells and fibroblasts demonstrated an increased expression of uPAR after exposure to IL-4 or -13, whereas uPA was highly expressed by epithelial cells exposed to IL-4. PAI-1 levels in culture medium were increased in IL-4-exposed epithelial cells compared to nonstimulated cells and were decreased in fibroblast culture. Increased expression of fibrinolytic system components and imbalance between plasminogen activators and PAI may be involved in the pathogenesis of severe allergic conjunctivitis, thus contributing to inflammatory cell migration and tissue remodeling.