and VKC Require Long-term Strategies
WILLIAM L. MILLER, OD, PHD, FAAO
less than 3 percent of all allergic conjunctivitis cases, atopic keratoconjunctivitis
(AKC) and vernal keratoconjunctivitis (VKC) are more severe forms of allergic disease
with increasing likelihood with
the increasing likelihood of corneal damage and vision loss. AKC and VKC patients
can present with bilateral severe itching, thick ropy discharge, conjunctival hyperemia
and photophobia. Their chronic and severe clinical presentation will bring about
many therapeutic challenges. Demographics and associated systemic signs and symptoms
can help you make the correct diagnosis between AKC and VKC.
Signs and Symptoms
1. Clinical VKC signs may include large, cobblestone-like papillae.
Typically, VKC affects males between ages 3 and 20 with most cases
manifesting before age 10. Increased prevalence in males decreases with age. New
diagnoses of VKC are rare after age 30. Relatively rare in the United States, Canada
and Australia, it occurs more in the Mediterranean Sea and West African areas. It
tends to be more severe in late spring to summer, but can be present throughout
the year. Clinical signs may include large, cobblestone-like papillae (Figure 1),
Horner-Trantas dots at the limbus, punctate keratopathy and corneal epithelial shield
AKC is typically found in patients ages 20 to 50 with a history
or family history of atopic dermatitis or asthma. Common signs are lid eczema, blepharitis,
meibomitis, tarsal margin keratinization, conjunctival subepithelial fibrosis, fornix
foreshortening, symblepharon formation, giant papillae, corneal SPK, corneal neovascularization
and persistent corneal epithelial defects.
Chronic Disease, Treatment
Treatments represent long-term management that often frustrates
both you and the patient. You can manage mild forms as you would seasonal allergies
(topical antihistamine medications and dual-action medications that contain antihistamine
and mast cell stabilizers.) However, you can manage many patients with a pulsed
therapy of topical corticosteroids. Because both diseases and treatment are chronic,
you must monitor for cataracts and glaucoma development. Common dosage for topical
corticosteroids such as dexamethasone 0.1% and prednisolone phosphate
1.0% may be six to eight times a day for seven to 10 days. Newer medications focus
on targeting cellular components of conjunctival response. These include the immunosuppressive
cyclosporine A and chemokine or cytokine antagonistic agents.
Cyclosporine A is reported to help in AKC and VKC by decreasing
interleukin-2 release. Chemokine and cytokine antagonists interrupt up-regulation
of other inflammatory factors such as IgE, eosinophils and neutrophils.
You may need to administer additional therapeutic approaches in
cases of shield ulcer formation (VKC) or persistent epithelial defects (AKC) where
a combination antibiotic/steroid such as loteprednol etabonate and tobramycin
ophthalmic suspension (Zylet, [Bausch & Lomb]) or tobramycin 0.3% and dexamethasone
0.1% (Tobradex, [Alcon]) may be useful to reduce ocular symptoms and provide prophylaxis
against secondary infections.
Dr. Miller is on the faculty
at the University of Houston College of Optometry. He is a member of the American
Optometric Association and serves on its Journal Review Board. You can reach him
Contact Lens Spectrum, Issue: January 2006