Vernal catarrh is a allergic disorder of children characterized by chronic inflammation of ocular surface.

1. A 8 year old male child presented to the OPD with
severe itching, mucous discharge and blurring of
vision of both left and right eyes. The patient is
known case of asthma and seasonal allergies. The
patient suffered from seasonal allergic rhinitis
2 weeks ago and he is on medication. On
examination there is gelatinous yellow-gray
infiltrates at the limbus and
presence of giant papillae at the upper tarsal
conjunctiva of both eyelids. What is your clinical
diagnosis ?

2. By : SUGUNESHWARAN R (89)
SRIRAMKUMAR R (88)
SUWATHEESWARAN M (91)
S.UMASHRI (94)

3. INTRODUCTION
• Vernal keratoconjunctivitis also Spring catarrh or Vernal catarrh
• It is potentially sight-threatening allergic disorder of children,
characterized by chronic inflammation of the ocular surface
• It is recurrent, bilateral, interstitial, self limiting, allergic inflammation
of conjunctiva having a periodic seasonal incidence.
• It is due to hypersensitivity reaction to some exogeneous allergens
like pollen grains

4. ETIOLOGY
• PREDISPOSING FACTORES
 Age: 4-20 years
Gender: boys> girls
Season : summer (aka warm weather conjunctivitis)
Climate: prevalence tropic > temperate >>> cold climate (non existant)
Family history of atopy (40-60% patients)
 other atopic manifestations (40-75% patients) : eczema or asthma or
hay fever
 Due to Th2 lymphocyte alteration and the exaggerated IgE response
to common allergens is a secondary event.

6. PATHOLOGY
 CONJUCTIVAL EPITHELIUM
 The mast cells, eosinophils that present in papillary
region will undergo hyperplasia due to which there is a
downward projections into subepithelial tissues
 ADENOID LAYER
 Will show marked cellular infiltration by mast cells,
eosinophils, plasma cells, lymphocytes and histiocytes
 FIBROUS LAYER
 This layer undergoes proliferation and later undergoes
hyaline changes
 CONJUCTIVAL VESSELS
 These vessels show proliferation, increased permeability
and vasodilation
Leads to formation of
multiple papillae in
the upper tarsal
conjunctiva

7. SYMPTOMS
• BURNING AND ITCHING SENSATIONS. ITCHING IS
MORE MARKED IN PALPEBRAL FORM OF DISEASE
• MILD PHOTOPHOBIA
• LACRIMATION
• STRINGY DISCHARGE (ropy or mucoid)
• HEAVINESS OF EYELIDS
CLINICAL COURSE :
• SELF LIMITING AND USUALLY BURNS OUT SPONTANEOUSLY AFTER
5-10 YEARS

8. CLINICAL MANIFESTATIONS IN
CONJUCTIVA
PALPEBRAL
VKC
BULBAR
VKC
MIXED
VKC

9. PALPEBRAL VKC
• Present in upper tarsal conjunctiva
of both eyes in involved
• COBBLE STONE or PAVEMENT
STONE : hard, flat topped papillae
fashion along the conjunctival
hyperemia
• Papillae may hypertrophy to
produce cauliflower like structures
–GIANT PAPILLAE
• White ropy discharge is present
• Differential diagnosis :it needs to be
differentiated with trachoma with
TRACHOM
A

10. BULBAR VKC
• Dusky red triangular congestion
of bulbar conjunctiva in palpebral
part
• Limbal papillae occurs as
gelatinous, thickened confluent
accumulations of tissue around
limbus
• Horner Tranta spots: it is discrete
whitish raised dots along the
limbus

11. MIXED VKC
• Combined of both
palpebral and bulbar
forms

12. CLINICAL
MANFESTATIONS IN
CORNEA

13. VERNAL KERATOPATHY
• Corneal involvement in vernal keratoconjunctivitis is called as VERNAL
KERATOPATHY.
• It is more common with palpebral form of VKC.

14. TYPES OF LESIONS
• Types of lesions produced are :
1) Superior punctate epithelial keratitis
2) Epithelial macro erosions
3) Vernal corneal plaques
4) Ulcerative vernal keratitis
5) Subepithelial scarring
6) Pseudogerontoxon

15. 1) SUPERIOR PUNCTATE EPITHELIAL KERATITIS :
Involves upper cornea , associated with palpebral VKC.
Caused by irritation from the inflamed tarsal conjunctiva.
Stained with – Rose Bengal stain and fluorescent dyes.

16. 2) EPITHELIAL MACRO EROSIONS :
due to coalescence of punctate lesions and here BOWMAN’S membrane is intact
3) VERNAL CORNEAL PLAQUES :
due to coating of eroded areas with exudate.

17. 4) ULCERATIVE VERNAL KERATITIS :
SHIELD ULCERATION , presenting as shallow transverse ulceration in
upper cornea.
due to enlargement of epithelial macro erosions.
complicated by bacterial keratitis.

18. 5) SUBEPITHELIAL SCARRING - occurs as a ring scar.
6) PSEUDOGERONTOXON
develops in recurrent limbal VKC
characterised by CUPID’S BOW outline.

19. TREATMENT AND MANAGEMENT

20. TREATMENT
1. Topical anti-allergic & anti-inflammatory drugs
• Dual action antihistamine & mast cel stabilizers
-control & prevention exacerbation
-1st line of treatment in mild to severe case
-olopatadine(0.1%),azelastine,bepotastine(1.5%)
• Mast cell stabilizers
-Sodium cromoglycate(2%) drops 3-4 times a day controlling VKC
especially atopic cases

21. • Topical steroids
-Effective in all VKC
-reserved for moderate to severe & recalcitrant cases as they cause
steroid induced glaucoma
-monitoring of IOL is very important
-intensive but short tapering course
i.e instillation (2 hrs) for 7days tapering dose for 3-4
weeks
-
fluorometholone(0.1%),loteprednol(0.5%),prednisolone,betamethasone,
dexamethasone
• Topical immunomodulators
-indicated whed steroids are ineffective,inadequate,or poorly
tolerated, or given as steroid sparing agent in severe disease
-cyclosporine(0.5-1%)
tacrolimus(0.03% ointment)-------refractory cases

22. 2. Topical lubricating and mucolytics
• Artificial tears – carboxy methyl cellulose – soothing effect
• Acetyl cysteine(0.5%) – mucolytics – early plaque formation
3. Systemic therapy
• Oral antihistamines – itching in severe cases
• Oral steroids – advanced, very severe, non-responsive cases
4. Treatment of large papillae
• Very large papillae can be tackled
• Supratarsal injection of long acting steroid
• Cryoapplication
• Surgical exciion – extraordinarily large papillae

23. SUPPORTIVE MEASURES
• Dark goggles to prevent photophobia
• Cold compresses and ice packs – soothing effect
• Eye rubbing should be avoided as it causes mast cell degranulation
• Change of places from hot to cold area is recommended for recalcitrant
cases

24. TREATMENT FOR VERNAL KERATOPATHY
• Punctate epithelial keratitis requires no extra treatment except
instillation of steroids should be increased
• Large vernal plaque – surgical excision by superficial keratectomy
• Severe shield ulcer resistant to medical therapy may need surgical
treatment in form of debridement, superficial keratectomy, excimer laser
therapeutic keratectomy as well as amniotic membrane transplantation
to enhance re-epithelialization