Vernal Keratoconjunctivitis

AUTHORS:
Jared S. Ellis, MD¹ • Katie Muhammad Reed, MD² • Tiffani Y. Thomas, MD³ • Larab Ahmed, MD⁴

AFFILIATIONS:
¹Associate Professor of Family Medicine, University of Alabama Tuscaloosa Family Medicine Residency Program, Tuscaloosa, Alabama
²Assistant Professor, Baylor College of Medicine, Houston, Texas
³Assistant Professor, University of Alabama Tuscaloosa Family Medicine Residency Program, Tuscaloosa, Alabama
⁴Resident Physician, University of Alabama Tuscaloosa Family Medicine Residency Program, Tuscaloosa, Alabama

CITATION:
Ellis JS, Muhammad Reed K, Thomas TY, Ahmed L. Vernal keratoconjunctivitis. Consultant. 2022;62(7):e26-27. doi:10.25270/con.2021.12.00011

Received July 21, 2021. Accepted August 17, 2021. Published online December 23, 2021. 

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Jared S. Ellis, MD, University of Alabama - Tuscaloosa, Box 870377, Tuscaloosa, AL 35487 (jsellis1@ua.edu)

A 7-year-old boy presented with his parents to our mobile medical mission team in rural Kenya, Africa. He had chronic ocular symptoms and was the first among several children with similar findings.

Through the assistance of a translator, his symptoms were described as ocular itching, tearing, burning, pain, foreign body sensation, blurred vision, and photophobia. These symptoms had waxed and waned for several years. His symptoms were typical of vernal keratoconjunctivitis (VKC).^1-3 He also had rhinorrhea and intermittent dyspnea that was worse during the spring and summer months.

Physical examination. Findings from an eye examination were typical for VKC^1-3 and included raised gelatinous, yellow-grey limbic deposits with medial conjunctival injection (Horner-Trantas dots), episcleral hyperemia, and photophobia. Further examination revealed boggy nasal congestion and clear rhinorrhea, as well as eczema. Other typical findings of VKC may include conjunctival and sticky, nonpurulent mucus discharge, giant cobblestone-like papillae on the upper tarsal conjunctiva, ptosis, blepharospasm, and superficial keratopathy.^1-4

Differential diagnoses. These ocular examination findings were unfamiliar to our medical team at the time, and various allergic and infectious etiologies were considered including atopic keratoconjunctivitis, giant papillary conjunctivitis, scarring secondary to irritant conjunctivitis, uveitis, episcleritis or scleritis, chlamydial and gonococcal conjunctivitis, or viral conjunctivitidies. The diagnosis of VKC was made when the medical team emailed a photograph of the patient’s eye to an ophthalmology colleague 8 time zones away.

Discussion. VKC is more prevalent in boys than girls, with some estimates showing an odds ratio (OR) of 4.23.² Patients typically present between ages 5 and 25 years, with a median age of onset between 10 and 12 years; however, there are reports of patients as young as 5 months.^1,4 It is most common in highly polluted areas with hot and dry climates in West and East Africa, the Mediterranean basin, the Middle East, Japan, India, and South America.^1,5,6 Symptoms are often perennial but are typically worse during the spring and summer months, hence the term “vernal.” VKC is a major cause of hospital referrals among children in Africa, the Middle East, and Asia. In Africa, VKC is responsible for the highest percentage (21.0%) of children presenting to general eye clinics and causes of school nonattendance. More than a quarter of 2250 children seen at a tertiary referral pediatrics eye clinic in East Africa had VKC.²

VKC is typically self-limited and often subsides after puberty.² However, based on the age of onset, it may take years to fully resolve. Vision loss is rare with VKC but may occur with the development of corneal scarring, keratoconus, neovascularization, cataracts, and glaucoma from prolonged unsupervised use of topical steroids.^1,2 Approximately 4.6% of patients with VKC develop some degree of visual impairment.¹

Treatment. The pathophysiology is complex but largely mediated by immunoglobulin E. One study showed a higher prevalence of close animal contact.² Approximately 30% of patients in another study showed a positive antinuclear antibody titer.⁶ Most patients only require treatment during locally specific seasons. Intervention is based on the severity of disease and assumes availability and affordability, often a challenge in the resource-poor environments that VKC typically occurs. Prophylactic measures may include environmental allergen control and medications such as topical mast-cell stabilizers (eg, lodoxamide, nedocromil, pemirolast). Symptomatic treatment for mild disease may include topical H1-antihistamine drops. For moderate to severe disease, a short course of topical corticosteroids (eg, dexamethasone), topical cyclosporin, or allergen Immunotherapy may be considered, but longer-term use should be avoided.^1,5,7  

Conclusions. In our patient and for subsequent patients we saw in Kenya with these symptoms, no topical therapies were available, and oral antihistamines were provided for symptomatic relief. Follow-up with our team was not possible, and referral to ongoing specialty care was implausible. Procurement of more-appropriate therapies will be sought in preparation for return trips to the area.

References

1. Kumar S. Vernal keratoconjunctivitis: a major review. Acta Ophthalmol. 2009;87(2):133-147. https://doi.org/10.1111/j.1755-3768.2008.01347.x

2. Alemayehu AM, Yibekal BT, Fekadu SA. Prevalence of vernal keratoconjunctivitis and its associated factors among children in Gambella town, southwest Ethiopia, June 2018. PLoS One. 2019;14(4):e0215528. https://doi.org/10.1371/journal.pone.0215528

3. La Rosa M, Lionetti E, Reibaldi M, et al. Allergic conjunctivitis: a comprehensive review of the literature. Ital J Pediatr. 2013;39:18. https://doi.org/10.1186/1824-7288-39-18

4. Ukponmwan CU. Vernal keratoconjunctivitis in Nigerians: 109 consecutive cases. Trop Doct. 2003;33(4):242-245. https://doi.org/10.1177/004947550303300419

5. De Smedt S, Wildner G, Kestelyn P. Vernal keratoconjunctivitis: an update. Br J Ophthalmol. 2013;97(1):9-14. https://doi.org/10.1136/bjophthalmol-2011-301376

6. Zicari AM, Capata G, Nebbioso M, et al. Vernal Keratoconjunctivitis: an update focused on clinical grading system. Ital J Pediatr. 2019;45(1):64. https://doi.org/10.1186/s13052-019-0656-4

7. Al-Akily SA, Bamashmus MA. Ocular complications of severe vernal keratoconjunctivitis (VKC) in Yemen. Saudi J Ophthalmol. 2011;25(3):291-294. https://doi.org/10.1016/j.sjopt.2011.02.001