An update in vernal keratoconjunctivitis
Year: 2025
Type: article
Abstract: The profile of allergic conjunctivitis covers a range of ocular allergic inflammatory conditions, which can be mild, as in seasonal allergic conjunctivitis, or perennial, both of which are known to be associated with environmental allergens. These usually tend to occur without corneal involvement and may be associated with upper respiratory allergy as well. The more severe forms include vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC), in which the severity of the disease morbidity can be variable and corneal involvement can occur as well. While the former is associated with seasonal exacerbations due to environmental allergens, the latter shows a genetic predisposition to systemic atopy of the respiratory tract and dermatological involvement. Giant papillary conjunctivitis is due to mechanical irritation such as chronic contact lens wear. VKC is an IgE and Th2 immune-mediated allergic ocular surface inflammation, which can be palpebral predominant (tarsal form), limbal predominant (limbal form), or mixed. Traditionally, scoring values were assigned as 0 for absent, 1 for mild, 2 for moderate, and 3 for severe for each of signs and symptoms of the clinical manifestations.[1] Bonini grading system[2] provided a scoring based on clinical manifestations, with the grading comprising Grade 0 – Quiescent (Absence of symptoms); Grade 1 – Mild intermittent: Presence of occasional symptoms with no corneal involvement; 2 – Moderate intermittent (2A) or Moderate persistent (2B) with presence of symptoms along with photophobia and no/or slight corneal involvement; Grade 3 – Severe: presence of moderate to severe persistent symptoms along with photophobia, corneal involvement with superficial punctate keratitis, and presence of giant papillae and/or Horner–Trantas dot; Grade 4 – Very severe: with severe persistent symptoms of daily itching, photophobia, and mucous discharge with diffuse superficial keratopathy/corneal erosions and/or corneal ulcerations and/or Horner–Trantas dots with injection and swelling; and Grade 5 – representing occasional symptoms with signs of conjunctival fibrosis without corneal involvement. The 5-5-5 exacerbation grading scale is another clinical assessment grading for the severity of allergic conjunctival disease but not specific for VKC.[3] This grading scale assigned point grade consists of clinical assessment as three graded groups (100-point grade, 10-point grade, and 1-point grade) [(i) 100-point-grade group (with 100 points assigned for each clinical sign of active giant papillae, gelatinous infiltrates of the limbus, exfoliative epithelial keratopathy, shield ulcer and giant papillae inflammation in lower conjunctiva; (ii) 10-point-grade group (with 10 points assigned for each clinical sign of blepharitis, papillary proliferation, Horner–Trantas spots, bulbar conjunctiva edema, and superficial punctate keratopathy; and (iii) 1-point-grade group (with 1 point assigned for each clinical sings of papillae at upper palpebral conjunctiva, follicular lesion at lower palpebral conjunctiva, hyperemia of palpebral conjunctiva, hyperemia of bulbar conjunctiva, and increased lacrimation]. Another grading system was developed to enable detection of more severe forms of VKC which are at greater risk of recurrence, corneal ulceration, and worse final visual outcome.[4] The recent Japanese guidelines of allergic conjunctival diseases (not specific for VKC) elaborated a more detailed disease severity assessment grading [Table 1].[5] The specificity of clinical symptoms were defined to be high when ocular itching was associated with giant papillae along with limbal involvement and shield ulcers and moderate in the presence of conjunctival edema, follicle, papillary proliferation, corneal erosion, punctate keratopathy, and corneal plaque.[5] The diagnostic criteria for conjunctival allergic disease were further elaborated in association with systemic allergy findings in this guidelines paper [Table 2].[5]Table 1: Clinical Severity Assessment (Japanese guidelines recommendations)[ 5 ]Table 2: Criteria for clinical diagnosis[ 5 ]These classification/grading scales help to prognosticate conjunctival allergic disease, with disease severity being related to a greater number of annual recurrences, a higher number of visits, and a lower final visual acuity.[4] The grading significance of disease severity classification is important in decision making in therapy, with mild disease warranting topical antiallergics and immunomodulators, moderate disease requiring an addition of topical low-potency steroids, and severe disease mandating topical high-potency steroids and interventions such as supratarsal steroid injections, giant papillae cryotherapy, and excision with amniotic/mucus membrane grafting. With the evolving understanding of the role of etiopathogenesis of altered sphingolipid metabolism on the ocular surface of severe refractory perennial cases of VKC, a more prudent classification system will enable identification of these to initiate a targeted therapy approach.[6] The definition of severity in chronic VKC has been varied in various studies. The severity grading system proposed by Gokhale et al.[7] categorized it as mild, moderate-intermittent, moderate-chronic, severe, and blinding subtypes with an inflammation interval period of lesser than one month qualifying as chronic and giant cobblestone papillary upper tarsal inflammation, shield ulcers and corneal scar, annular limbitis, limbal stem cell deficiency, and scarring, defining blinding VKC. Corneal morbidity is characterized by pseudogerontoxon, superficial punctate keratitis which can evolve into epithelial erosion, ulcer, plaque keratitis, and scar formation. Corneal lesions tend to be more frequent in the palpebral form than limbal form of VKC.[1] Recent papers have highlighted the recognition of adult-onset VKC as a distinct clinical entity of a milder form[8] and need for aggressive management of the clinical profile in VKC in HIV patients with decreased CD4 counts.[9] Recent emphasis has been on the inclusion of implication of VKC on the quality of life (QoL) in the severity assessment grades. The existing QoL in children with VKC questionnaire (QUICK)[10] seems to lack integration of daily activity score with clinical sign scores necessitating the correlation of parent and patient’s psychological assessment with QoL and clinical scores.[1] Most of the existing VKC grading centers around clinical activity, while the new universal grading system uses prior ocular history and corneal signs which will be useful to assess patients in which the disease in quiescent [Table 3].[11] Recent clinical study to assess efficacy of tear tacrolimus levels in cases of VKC treated with cutaneous application of tacrolimus 0.1% ointment over the eyelid skin used composite assessment scoring scale integrating clinical assessment and treatment scores to map out severity scales.[12] All these help toward enhancing the clinical severity assessment modalities in VKC, which is imperative in the strategizing treatment options optimally.Table 3: Universal grading system of VKC
Source: Indian Journal of Ophthalmology
Author: Murugesan Vanathi
Institution: All India Institute of Medical Sciences
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4414512600