Vernal keratoconjunctivitis (VKC) or Spring catarrh is a recurrent, bilateral, and self limiting inflammation of conjunctiva

Conjunctiva

The conjunctiva covers the sclera and lines the inside of the eyelids. It is composed of rare stratified columnar epithelium.-Function:...

, having a periodic seasonal incidence.

Etiology

VKC is thought to be an allergic disorder in which IgE mediated mechanism play a role. Such patients often give family history of other atopic diseases such as hay fever

Hay Fever

Hay Fever is a comic play written by Noël Coward in 1924 and first produced in 1925 with Marie Tempest as the first Judith Bliss. Laura Hope Crews played the role in New York...

, asthma

Asthma

Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...

 or eczema

Eczema

Eczema is a form of dermatitis, or inflammation of the epidermis . In England, an estimated 5.7 million or about one in every nine people have been diagnosed with the disease by a clinician at some point in their lives.The term eczema is broadly applied to a range of persistent skin conditions...

 and their peripheral blood shows eosinophilia

Eosinophilia

Eosinophilia is a condition in which the eosinophil count in the peripheral blood exceeds 0.45×109/L . A marked increase in non-blood tissue eosinophil count noticed upon histopathologic examination is diagnostic for tissue eosinophilia. Several causes are known, with the most common being...

 and increased serum IgE

IGE

IGE was one of the largest services company buying and selling virtual currencies and accounts for MMORPG. During its peak time, it had offices in Los Angeles, China , and headquarters & customer service centre in Hong Kong. IGE was one of the main monopoly in virtual economy services, also known...

 levels.

Predisposing factors

• Age & sex- 4–20 years; more common in boys than girls.
• Season- More common in summer. Hence the name Spring catarrh is a misnomer. Recently it is being labelled as Warm weather conjunctivitis.
• Climate- More prevalent in the tropics.

Pathology

• Conjunctival epithelium
  Epithelium
  Epithelium is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. Epithelial tissues line the cavities and surfaces of structures throughout the body, and also form many glands. Functions of epithelial cells include secretion, selective...
  
   undergoes hyperplasia
  Hyperplasia
  Hyperplasia means increase in number of cells/proliferation of cells. It may result in the gross enlargement of an organ and the term is sometimes mixed with benign neoplasia/ benign tumor....
  
   and sends downward projection into sub-epithelial tissue.
• Adenoid layer shows marked cellular infiltration by eosinophils, lymphocytes, plasma cells and histiocytes.
• Fibrous layer show proliferation which later undergoes hyaline changes.
• Conjunctival vessels also show proliferation, increased permeability and vasodilation.

Clinical picture

• Symptoms- VKC is characterised by marked burning and itchy sensations which may be intolerable and accentuates when patient comes in a warm humid atmosphere. Associated symptoms include mild photophobia
  Photophobia
  Photophobia is a symptom of abnormal intolerance to visual perception of light. As a medical symptom photophobia is not a morbid fear or phobia, but an experience of discomfort or pain to the eyes due to light exposure or by presence of actual physical photosensitivity of the eyes, though the term...
  
  , lacrimation, stringy discharge and heaviness of eyelids.

• Signs of VKC can be described in three clinical forms.

1. Palpebral form- Usually upper tarsal conjunctiva of both the eyes is involved. Typical lesion is characterized by the presence of hard, flat topped papillae arranged in cobble stone or pavement stone fashion. In severe cases papillae undergo hypertrophy to produce cauliflower like excrescences of ' giant papillae '.
2. Bulbar form- It is characterised by dusky red triangular congestion of bulbar conjunctiva in palpebral area, gelatinous thickened accumulation of tissue around limbus and presence of discrete whitish raised dots along the limbus
   Limbus
   Limbus may refer to:* Limbu people, a ethnic group in Asia, an indigenous ethnic group of Nepal.* Corneal limbus* Limbus , a Swedish punk rock band* Limbo, the temporary status of the souls of good persons who died but did not go to Heaven...
   
    (Tranta's spots).
3. Mixed form- Shows the features of both palpebral and bulbar types.

Vernal keratopathy

Corneal involvement in VKC may be primary or secondary due to extension of limbal lesions. Vernal keratopathy includes 5 types of lesions.

1. Punctuate epithelial keratitis.
2. Ulcerative vernal keratitis.
3. Vernal corneal plaques.
4. Subepithelial scarring.
5. Pseudogerontoxon.

Treatment

• Local therapy- Topical steroids are effective. Commonly used solutions are of fluorometholone
  Fluorometholone
  Fluorometholone is a corticosteroid, most often used after laser-based refractive surgery. It is marketed under the brand names FML and Flarex ....
  
  , medrysone
  Medrysone
  Medrysone is a corticosteroid used in optometry and ophthalmology....
  
  , betamethasone
  Betamethasone
  Betamethasone is a potent glucocorticoid steroid with anti-inflammatory and immunosuppressive properties. Unlike other drugs with these effects, betamethasone does not cause water retention. It is applied as a topical cream, ointment, foam, lotion or gel to treat itching...
  
   or dexamethasone
  Dexamethasone
  Dexamethasone is a potent synthetic member of the glucocorticoid class of steroid drugs. It acts as an anti-inflammatory and immunosuppressant...
  
  . Mast cell stabilizers such as sodium cromoglycate (2%) drops 4-5 times a day are quite effective in controlling VKC, especially atopic ones. Azelastine eyedrops are also effective. Topical antihistamines can be used. Acetyl cysteine (.0.5%) used topically has mucolytic properties and is useful in the treatment of early plaque formation. Topical Cyclosporine is reserved for unresponsive cases.
• Systemic therapy- Oral antihistamines and oral steroids for severe cases.
• Treatment of large papillae- Cryo application, surgical excision or suupratarsal application of long acting steroids.
• General measures include use of dark goggles to prevent photophobia, cold compresses and ice pack for soothing effects, change of place from hot to cold areas.
• Desensitization has also been tried without much rewarding results.
• Treatment of vernal keratopathy- Punctuate epithelial keratitis require no extra treatment except that instillation of steroids should be increased. Large vernal plaque requires surgical excision. Ulcerative vernal keratitis require surgical treatment in the form of debridement, superficial keratectomy, excimer laser therapeutic keratectomy, as well as amniotic membrane transplantation to enhance re-epithelialisation.