Severe Vernal Keratoconjunctivitis Research Articles

Evaluation of Meibomian Gland Structure and Function in Patients with Vernal Keratoconjunctivitis Using Non Contact Meibography and Lipid Layer Interferometry

ABSTRACT Purpose This study evaluated the structural and functional impact of vernal keratoconjunctivitis (VKC) on meibomian glands (MGs) using a combination of noncontact meibography and lipid layer interferometry. Methods In this observational study 50 patients with moderate persistent or severe VKC and 50 age-matched controls underwent MG imaging and lipid layer thickness (LLT) measurements with Lipiview II. Image J software was used to assess MG loss (meibograde) in both lids. All patients underwent dry eye evaluation comprising tear break-up time (TBUT), ocular surface staining (OSS), Schirmer I scoring, and meiboscoring (expressibility and quality of meibum secreted). Results Meibograde, OSS score, and meiboscore was higher in cases (2.68 ± 0.96, 0.580 ± 1.07, and 0.56 ± 0.95 respectively) than controls (1.80 ± 0.67, 0.00 ± 0.00, 0.22 ± 0.47 respectively) (p < 0.001, 0.001, 0.025 respectively). LLT and TBUT was lower in cases (54.58 ± 9.43 nm and 4.92 ± 3.09 sec respectively) than controls (70.14 ± 22.50 nm and 12.02 ± 2.73 sec respectively) (both p’s = 0.001). Both groups had comparable Schirmer I scores. Conclusion Children with VKC have significant MG dropouts, deterioration in meibum quality and a thinner and less stable tear film. VKC patients are thus prone to a vicious cycle of inflammation attributable both to the allergic component and to deterioration in MG structure and function. Co-management of MG dysfunction warrants as much attention as the allergic component itself.

Evaluation of Meibomian Gland Structure and Function in Patients with Vernal Keratoconjunctivitis Using Non Contact Meibography and Lipid Layer Interferometry

ABSTRACT Purpose This study evaluated the structural and functional impact of vernal keratoconjunctivitis (VKC) on meibomian glands (MGs) using a combination of noncontact meibography and lipid layer interferometry. Methods In this observational study 50 patients with moderate persistent or severe VKC and 50 age-matched controls underwent MG imaging and lipid layer thickness (LLT) measurements with Lipiview II. Image J software was used to assess MG loss (meibograde) in both lids. All patients underwent dry eye evaluation comprising tear break-up time (TBUT), ocular surface staining (OSS), Schirmer I scoring, and meiboscoring (expressibility and quality of meibum secreted). Results Meibograde, OSS score, and meiboscore was higher in cases (2.68 ± 0.96, 0.580 ± 1.07, and 0.56 ± 0.95 respectively) than controls (1.80 ± 0.67, 0.00 ± 0.00, 0.22 ± 0.47 respectively) (p < 0.001, 0.001, 0.025 respectively). LLT and TBUT was lower in cases (54.58 ± 9.43 nm and 4.92 ± 3.09 sec respectively) than controls (70.14 ± 22.50 nm and 12.02 ± 2.73 sec respectively) (both p’s = 0.001). Both groups had comparable Schirmer I scores. Conclusion Children with VKC have significant MG dropouts, deterioration in meibum quality and a thinner and less stable tear film. VKC patients are thus prone to a vicious cycle of inflammation attributable both to the allergic component and to deterioration in MG structure and function. Co-management of MG dysfunction warrants as much attention as the allergic component itself.

Cyclosporine A and autologous serum efficacy for treatment of vernal keratoconjunctivitis

Purpose To compare the effectiveness of using Cyclosporine A (CsA) eye drops with a concentration of 0.05% alone versus using eye drops containing both CsA of 0.05% concentration combined with autologous serum (AS) of 20% used together for treating vernal keratoconjunctivitis (VKC) which were moderate to severe. Methods A prospective comparative noninterventional case series was carried out at the Ophthalmology Department at Kafrelsheik University, involving 40 individual patients with moderate to severe VKC sorted into two groups; 20 patients using CsA 0.05% eye drops as group A and 20 patients in group B using eye drops of CsA 0.05% combined with AS eye drop of 20% concentration for treating VKC for 12 weeks, 4 times daily. Results According to the scores recorded for symptoms and signs, the difference detected statistically was of no significance among the two involved study groups as regards the baseline score (P=0.783, and 0.137, respectively). While the scores reported for the symptoms and signs were statistically lower significantly among group B other than observed among group A as determined at the 4th week (P=0.015, and 0.004, respectively), 8th week (P&lt;0.001, for both), and 12th week (P=0.001, and 0.002, respectively). Regarding side effects of treatment, 12 patients had a burning sensation, eight of them in group A and four patients in group B, with not reach to significant level between the studied groups during the follow-up visits (P=0.382) Conclusions We concluded a higher efficacy of using combined eye drops of CsA 0.05% and AS 20% for treating VKC than CsA 0.05% eye drops alone.

New and future treatment approaches for allergic conjunctivitis

In severe and recurrent ocular allergies conventional ophthalmic drugs can reach their limits, especially in chronic forms. The first novel immunomodulators and biologicals are already in clinical use and could provide relief. Based on the immunopathophysiological mechanisms of ocular allergies, possible targets for innovative treatment approaches are presented. An overview of promising new and future immunomodulators and biologicals and their modes of action is also given. Current reviews on ocular allergies and the treatment of systemic allergic diseases were screened. Case reports on the treatment of ocular allergy using immunomodulators and biologicals were analyzed. The clinical relevance and possible applications are presented. In chronic forms of ocular allergies, complex ocular surface inflammatory responses mediated via immunoglobulinE (IgE), mast cells, CD4-positive type 2 T‑helper cells and eosinophilic granulocytes are predominant. CyclosporineA 0.1% eyedrops have been approved in Europe since 2018 for children aged 4 years and older with severe vernal keratoconjunctivitis (VKC). In addition, case reports present promising data on the systemic off-label use of biologicals, such as dupilumab or omalizumab, in refractory VKC or atopic keratoconjunctivitis (AKC). Aprofound understanding of the immunopathophysiology of ocular allergies is necessary to detect further targets for future immunomodulators and biologicals. Currently, immunomodulatory therapy remains limited to cyclosporineA eyedrops. Other immunomodulatory agents, such as tacrolimus and biologicals can only be used off-label. Further studies on the controlled clinical use of these substances in the treatment of VKC or AKC are underway.

Long-Term Clinical Outcome of Tacrolimus Skin Ointment (0.03%) for the Treatment of Vernal Keratoconjunctivitis: A Quasi-Experimental Study.

Background Vernal keratoconjunctivitis (VKC) is an allergic conjunctival inflammation with severe ocular complications if left untreated. The current management regimen is plagued with adverse effects, long-term problems, and clinical relapses. Tacrolimus offers an alternative treatment option, and long-term studies are needed to determine its efficacy. Methods A two-year follow-up based study was conducted on moderate to severe VKC patients, who were prescribed tacrolimus skin ointment. The 5-5-5 exacerbation scale was used for the monitoring and grading severity of the disease. Analysis of variance (ANOVA) and intergroup comparisons were conducted on exacerbation scale scores among follow-ups. Results A significant reduction was observed in the total score of severity from baseline (203.17±102.05) to three months' follow-up (69.94±70.54), and it kept reducing for 18 months post therapy. Similar results with statistically significant reduction were observed for all grades of the scale. The relapse rate was 5.71% within a month after therapy cessation, and none of the other patients showed relapse afterward. No significant ocular and systemic complications were observed during the study. Conclusion Tacrolimus is effective in the long-term management of VKC without the complications of conventional steroid-based therapy.

Dendritic Cell Density and Morphology Can Be Used to Differentiate Vernal Keratoconjunctivitis from Allergic Conjunctivitis.

The aim of the study was to compare the distribution of corneal and conjunctival epithelial dendritic cells (DCs) in vernal keratoconjunctivitis (VKC), allergic conjunctivitis (AC), and non-allergic controls to examine if the allergy type causes differences in immune cell activation. The prospective study included 60 participants: 20 with VKC, 20 with AC, and 20 non-allergic controls. In vivo confocal microscopy was performed on the right eye. The locations scanned included the corneal centre, inferior whorl, corneal periphery, corneal limbus, and bulbar conjunctiva. The DCs were counted manually, and their morphology was assessed for the largest cell body size, the presence of dendrites, and the presence of long and thick dendrites. The DC density was higher in VKC and AC compared to non-allergic group at all locations (p ≤ 0.01) except at the inferior whorl. The DC density in VKC participants was significantly higher than in AC at the limbus (p < 0.001) but not at other locations. Both the AC and the VKC group had larger DC bodies at the corneal periphery and limbus compared to the non-allergic group (p ≤ 0.03). The study found a higher proportion of participants with DCs exhibiting long dendrites at both the corneal periphery in AC (p = 0.01) and at the corneal centre, periphery, and limbus in VKC, compared to the non-allergic group (p ≤ 0.001). In conclusion, a higher DC density at the limbus may be a marker of more severe VKC. DCs with larger cell bodies and a greater proportion of participants with DCs displaying long dendrites can be potential markers to differentiate allergy from non-allergy, and more severe forms of allergy from milder forms.

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.

Novel Insights in the Management of Vernal Keratoconjunctivitis (VKC): European Expert Consensus Using a Modified Nominal Group Technique.

Vernal keratoconjunctivitis (VKC) is a rare, severe allergic ocular disease, typically occurring in children and adolescents, that can have a significant impact on quality of life and lead to visual impairment. Long-term treatment may be necessary to tackle chronic inflammation and topical corticosteroid dependency must be minimised due to the risk of complications. There is a need for unified clinical guidance to aid the assessment, diagnosis and management of VKC across Europe. The aim of this expert panel (the EUR-VKC Group) was to provide clear guidance for primary care physicians and general ophthalmologists involved in the diagnosis and management of VKC. An expert group of seven European ophthalmologists was convened and a modified nominal group technique used to develop key recommendations on VKC management. The recommendations were subject to up to two rounds of voting using a 5-point Likert scale to ascertain consensus and the strength of each recommendation. Consensus was set at a predetermined threshold of ≥ 75.0% of experts selecting 'Strongly agree' or 'Agree'. A total of 47 recommendations were developed relating to the assessment of key of VKC, guidance on who and when to refer, as well as treatment-escalation pathways, long-term follow-up, and supportive care and education. All recommendations reached consensus after two rounds. The group emphasise how timely diagnosis and treatment initiation that is appropriate to disease severity are crucial to benefit patients with VKC. Patients with signs ('red flags') indicating severe VKC, or persistent mild-to-moderate VKC that is non-responsive following 2-4weeks of treatment, should be referred to a sub-specialist. The EUR-VKC Group provides recommendations on the assessment, diagnosis, management, referral and follow-up of patients with VKC. It also provides a framework to facilitate collaboration between primary care physicians, general ophthalmologists and sub-specialists to improve the outcomes for patients with VKC.

Steroid-sparing effect of ciclosporin A 1 mg/mL: 5-year case series of 107 children and young people with vernal keratoconjunctivitis

Background/aimsTo explore the steroid-sparing and other therapeutic effects of ciclosporin A (CsA) 1 mg/mL in the management of vernal keratoconjunctivitis (VKC).MethodsOpen retrospective single-group interventional consecutive cohort study (case series) of...

Ptosis in long standing VKC in young adults

Vernal keratoconjunctivitis (VKC) is an unusually severe sight-threatening allergic eye disease, occurring mainly in children. Children with VKC present with severe ocular symptoms, that is, severe eye itching and irritation, constant tearing, red eye, eye discharge, and photophobia. Though medically treated, some complications of the disease like ptosis may require surgical intervention, thus identifying the association of ptosis with VKC is of utmost importance. This study was done to see the relation between long-standing VKC and acquired ptosis in young adults.This was a hospital based non-comparative, observational study, conducted in the department of Ophthalmology, SKIMS Medical College Hospital, and Srinagar from March 2020 to May 2022. 60 patients upto the age of 40 years with any form of VKC were included in the study. Ocular examination included visual acuity testing, slit lamp biomicroscopic examination to evaluate corneal and conjunctival involvement, proper history and evaluation of ptosis.Mean age of cases was 16.23± 6.97. Out of 60 patients maximum were in the age group of 10-15 years (31.66%), followed by the age group of 15-20 years (21.66%). Out of total 60 cases 46(76.66%) were male and 14(23.33%) were female. Palpebral form of the disease was seen to be in most of the cases 53.33%, followed by mixed form of the disease in 28.33% and bulbar disease in 18.33% of the cases. Presence of acquired ptosis as a complication due to VKC was seen in 9(15%) patients. Out of these 9 patients 7 patients presented with unilateral ptosis and 2 patients presented with bilateral ptosis. Average duration of symptoms in these patients was 5.0±1.8 years, indicating that ptosis is a complication of long standing VKC. All these patients had palpebral or mixed form of VKC, none had bulbar form of the disease.Our study revealed that prolonged severe VKC may induce a lower position of the upper eyelid and eventually lead to ptosis, which is a non-reversible complication of VKC and requires surgical correction. Thus better primary eye care for the management of VKC in children may prevent this complication.

Efficacy and Safety of 0.1% Cyclosporine versus 2% Cyclosporine in the Treatment of Severe Vernal Keratoconjunctivitis in Children.

IntroductionVernal keratoconjunctivitis (VKC) is an inflammatory condition in children that can cause severe eye complications. Treatment is based on corticosteroid therapy during flare-ups, then antihistamines and cyclosporine in calmer periods. The dosage and posology of cyclosporine are subject to debate.MethodsThe aim of the study is to compare the evolution in symptomatic and clinical scores, and need for topical corticosteroid treatment in a population of children with severe VKC treated with two dosages of cyclosporine treatment (0.1% and 2%). Data were compiled on inclusion then every three months from March, with a total follow-up duration of 12 months. Data concerning patient evolutions and complications were collected for the two treatment groups.ResultsThe mean age of the 46 children was 8.8 ±2.4 years with age at onset of symptoms of 5.1 ± 0.9 years. The cohort was predominantly (65%) male. Corticosteroid dependence on inclusion was present in 52% of the children included. A significant improvement in the various symptomatic and clinical scores was observed following treatment with cyclosporine (0.1% and 2%). Use of topical corticosteroid treatment reduced from 19 drops per month on inclusion to 4 drops per month at 12 months. Safety was comparable for the two groups.ConclusionTreatments with cyclosporine 0.1% and 2% lead to a favourable evolution in clinical and symptomatic scores and reduced corticosteroid use. Cyclosporine 0.1% is an interesting alternative to the 2% dosage, particularly due to its availability and ease of handling.

Clinical effectiveness and local side effects of topical 0.05% cyclosporine in treatment of children with severe vernal keratoconjunctivitis

Purpose: To evaluate the therapeutic response of topical cyclosporine (CyS-A) in patients with vernal keratoconjunctivitis (VKC), resistant to topical mast cell stabilizer (MCS) and anti-histamine therapy. Study Design: Quasi experimental study. Place and Duration of Study: Qazi Hussain Ahmad Medical Complex, Nowshera, from April 2019 to August 2019. Methods: Forty patients, 30 males and 10 females, less than 18 years of age and diagnosed with Vernal Keratoconjunctivitis were enrolled in the study. All participants were graded based upon severity of the disease at presentation with a score of 0 for normal, 1 for mild, 2 for moderate and 3 for severe, for both symptoms and signs. Each patient received topical CyS-A 0.05%in QID regimen in addition to lubricating tear substitute. Followup was done for 04 months. Results: Clinical scoring was done at baseline and at the 1st, 2nd and 4th month following therapy. After 4 months of topical application, not only the patients improved symptomatically but their clinical signs also improved, which achieved a level of statistical significance (p &lt; 0.05). All participants completed the follow-up duration of therapy. Although Horner Tranta’s dot showed improvement, but comparison of baseline with 1st month values were statistically non-significant (p = 0.048). However, during 2nd and 4th month, the improvement achieved statistical significance (p = 0.013 and p = 0.006 respectively). None of the participants reported any bothersome local side effect. Conclusion: Topical cyclosporine 0.05% is effective in alleviating the symptoms and signs without any local side effects in resistant VKC. Key Words: Vernal keratoconjunctivitis, Cyclosporine, Cobblestone Papillae.

Incremental Concentrations of Tacrolimus Eye Drops as a Strategy for the Management of Severe Vernal Keratoconjunctivitis.

Purpose: To assess the effect of different concentrations of tacrolimus eye suspension on the epithelium and stromal keratocytes of human corneas and investigate whether it can be safely used for severe cases of vernal keratoconjunctivitis (VKC). Methods: Tacrolimus eye suspension was prepared in a range of concentrations of 0.005%, 0.01%, 0.05%, 0.1%, and 0.2%. Molecular analysis was performed ex vivo on human corneas (n = 18), obtained from the eye bank. Transparency and thickness of each cornea were measured while live/dead staining was performed using a triple labeling assay. An incremental concentration approach was then tested on three severe cases of VKC. Results: All tested tacrolimus concentrations showed no significant changes in corneal thickness or transparency. In corneas treated with 0.1%, rare scattered dead cells were observed, while the folds of corneal surfaces were mostly viable, unlike concentrations higher than 0.1% and lower than 0.05%. Stromal cell densities were highest in the 0.1% tacrolimus treatment condition. Incremental concentrations of tacrolimus suspension were shown to significantly improve VKC cases, where the concentration used for each case depended on the severity of the case. Conclusions: Topical administration of tacrolimus was not toxic to human corneal cells at all tested concentrations, and the 0.1% concentration has shown the best viability of the corneal tissue. Tacrolimus eye suspension was shown to be safe and effective for use in severe VKC and is proposed as a topical ocular immunosuppressant drug enabling clinicians to incrementally increase the drug concentration according to the clinical severity of the disease to achieve the optimal therapeutic response.

Ocular surface sphingolipids associate with the refractory nature of vernal keratoconjunctivitis: newer insights in VKC pathogenesis

BackgroundThe etiopathogenesis of vernal keratoconjunctivitis (VKC) is incompletely understood. Bioactive lipids play a key role in allergic disorders. This study focused on the sphingolipid metabolism on the ocular surface of...

Long-Term Safety and Efficacy of Tacrolimus 0.1% in Severe Pediatric Vernal Keratoconjunctivitis.

The aim of this study was to evaluate the safety and efficacy of tacrolimus 0.1% eye drops in a large population of pediatric patients affected by a severe form of vernal keratoconjunctivitis (VKC) who responded poorly to cyclosporine eye drops. This is a retrospective study based on standardized clinical charts and data collection of consecutive patients affected by severe VKC who responded poorly to cyclosporine eye drops topical treatment but treated with tacrolimus 0.1% eye drops with a follow-up of 18 months. Four clinical signs were graded for analysis: hyperemia, tarsal papillae, giant papillae, and limbal papillae. The blood tests for kidney and liver function and the tacrolimus level were studied. Visits were scheduled at baseline and at 3, 6, 12, and 18 months. Patients received tacrolimus 0.1% eye drops in both eyes 2 times daily. Four hundred thirty-one patients were included. Three hundred twenty-five patients were affected by a seasonal form, whereas the remaining 106 by a perennial form. Statistical analysis on each single score showed a positive relevance (P < 0.001) from baseline to all other visits. No local or systemic complications were recorded. Tacrolimus has been proposed as a treatment for severe forms of VKC. This study has confirmed the safety and efficacy of tacrolimus 0.1% eye drops in a large pediatric population of patients affected by a severe form of VKC who responded poorly to cyclosporine eye drops.

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.

Efficacy of montelukast in preventing seasonal recurrence of vernal keratoconjunctivitis in children.

Vernal keratoconjunctivitis is a chronic, seasonally exacerbated, allergic inflammation of the eye. The study aims to evaluate the efficacy and safety of oral montelukast in treating vernal keratoconjunctivitis in pediatric patients. This is a 26-week, prospective, randomized, open-label study. Fifty-eight patients were randomly assigned to two groups-the treatment (montelukast) and control groups. At the beginning of the study, both the groups received topical loteprednol etabonate (0.1%) in tapering doses for a month, and topical olopatadine (0.1%) for the first 3 months. Symptoms and signs observed before and after treatment and assigned scores were studied. The primary efficacy endpoint was change in the mean score on the visual analog scale (VAS) for each subjective symptom. The secondary efficacy endpoint was change in the total score of objective signs. The montelukast group showed clinically relevant improvements in the signs and symptoms of vernal keratoconjunctivitis, compared to the control group. There was considerable improvement in clinical signs. Individual symptoms such as redness, itching, foreign body sensation, and tearing showed significant improvement at 6 months follow-up. The gradual improvement in symptoms until the last visit was statistically more significant within montelukast group. Mean VAS score showed statistically significant improvement in itching (p < 0.001) and redness (p < 0.008) in montelukast group even at 3 months. No adverse events were reported in either group. Montelukast was found to be safe and effective as a long-term therapy to prevent relapse in moderate to severe vernal keratoconjunctivitis.

Les modalités d’utilisation de la ciclosporine locale pour l’allergie oculaire

Of the common allergic conjunctivitis in children, rare forms present more severe prognosis which include vernal keratoconjunctivitis and atopic keratoconjunctivitis. Vernal keratoconjunctivitis affects children mainly boys from 3 to 15 years old and represents a serious, descolarizing pathology affecting quality of life of the child. Atopic keratoconjunctivitis clearly affects adults more frequently with moderate to severe degrees of severity. Thus, the last few years have had the objective of developing innovative therapies to improve the management of these severe keratoconjunctivitis. It is essential to recognize the clinical form of these eye allergies for the implementation of appropriate treatment. Topical corticosteroids, although most often effective, can create dependence and moreover cause iatrogenic or even severe visual impairment complications. The latest studies on ciclosporin which is an immunosuppressive agent, have demonstrated major steroid-sparing effects. The proper use of topical cyclosporine must be well monitored. Nowadays, topical ciclosporine at 0.1%, has received the AMM for the indication of vernal keratoconjunctivitis and a new dosage at 2% received the AMM for the treatment of keratoplasty. Tacrolimus ointment having more powerful effects than cyclosporine is of interest in severe vernal keratoconjunctivitis and in fact especially in atopic keratoconjunctivitis. Therefore, in addition Tacrolimus treats atopic eyelid eczema. The various latest generation antiallergics can be useful in combination in ocular allergy. In very severe cases, Omalizumab, a human monoclonal antibody produced by the so-called recombinant DNA technique, selectively binds human immunoglobulin E (IgE) and has shown its effectiveness combined with ciclosporine in recent studies. Topical ciclosporine used appropriately can be a steroid-sparing agent in severe ocular allergy and improve the quality of life of children.

Efficacy of 2% Rebamipide Suspension for Vernal Keratoconjunctivitis: A Clinical Comparison with Topical Immune Modulators Cyclosporine and Tacrolimus

ABSTRACT Purpose To compare the efficacy of 2% rebamipide suspension with topical cyclosporine and tacrolimus for managing vernal keratoconjunctivitis (VKC) Methods In this prospective, interventional study, 38 patients with moderate to severe VKC were allocated to receive either 2% rebamipide in one eye and 0.03% tacrolimus ointment in the contralateral eye (n = 19) or 2% rebamipide in one eye and 0.05% cyclosporine in the contralateral eye (n = 19) for 12 weeks. Ten ocular signs and 7 symptoms were graded on a scale of 0-3 each for each eye at every visit. Results Total sign and symptom scores reduced significantly in all 4 subgroups (all p’s <0.05) at 12 weeks. Reduction of mean sign scores between rebamipide and tacrolimus (- 4.67 ± 4.63 and - 2.80 ± 3.18 respectively) and between rebamipide and cyclosporine (-6.00 ± 3.74 and -5.42 ± 3.68 respectively) was comparable. Reduction in symptom scores was also comparable between subgroups. Conclusion Our findings suggest that efficacy of topical rebamipide is comparable to topical cyclosporine and tacrolimus for managing moderate to severe VKC and it merits further evaluation as a novel steroid sparing alternative for this disorder.

Corneal and lens densitometry with Pentacam HR in children with vernal keratoconjunctivitis

ABSTRACT Clinical relevance Corneal and lens densitometry measurements provide clinically important information for the evaluation and monitoring of corneal and lens health in patients with vernal keratoconjunctivitis. Background To compare the corneal and lens densitometry values between paediatric patients with vernal keratoconjunctivitis (VKC) and healthy individuals. Methods This study included 72 eyes of 72 patients with VKC (25 with mild VKC [Group 1], 22 with moderate VKC [Group 2], and 25 with severe VKC [Group 3]), and 25 eyes of 25 healthy subjects (Group 4). Corneal and lens densitometry values were measured using Pentacam HR as follows: for corneal densitometry in two different corneal zones (0–2 and 2–6-mm) and four different corneal depths (at the total thickness, anterior, central, and posterior layers), and lens densitometry in three different lens zones (Zone 1: 2.0-mm, Zone 2: 4.0-mm, and Zone 3: 6.0-mm). Results In the 0–2-mm corneal zone for the total thickness and all three layers, corneal densitometry values in Group 3 were significantly higher than those in Groups 1, 2, and 4 (for all values p < 0.012). There was no significant difference in the mean corneal densitometry values between Groups 1 and 2 (for all values p > 0.05). In these groups, the mean corneal densitometry values were significantly higher than those in Group 4 for the anterior layer in the 0–2 and 2–6-mm corneal zones (for all values p < 0.012). The mean values for Zone 3 and average lens densitometry values in Groups 2 and 3 were significantly higher than those in Group 4 (p = 0.001 and p = 0.001, respectively). Conclusion The current study showed corneal clarity changes in patients with mild, moderate, and especially severe VKC. An increase in the lens densitometry values was also observed in patients with moderate and severe VKC than in healthy individuals.