This document presents a case study of a 10-year-old male student presenting with redness and itching in both eyes for 15 days. On examination, the patient was found to have mild eyelid edema, conjunctival congestion and papillae in both eyes. Based on the signs and symptoms, the patient was diagnosed with vernal keratoconjunctivitis (VKC). Treatment included topical medications which improved the symptoms over subsequent follow-ups. The document concludes with a discussion of VKC including its prevalence, symptoms, signs, classification, treatment options and management.

1. CASE PRESENTATION
Presenter:- Ramji pandey
C L Gupta eye institute moradabad (U.P)

2. DEMORAPHIC DATA
• DATE-06/06/2016
• MR.NO-P091486
• AGE/SEX- 10/MALE
• OCCUPATION- STUDENT
• ADD-KANTH MORADABAD UTTRA PRADESH,INDIA

3. HISTORY & CHIEF
COMPLAINTS
C/O- (OU)
• Redness,itching-15days.
• No H/o- other specific complant.
• No H/O –using glasses.
• No H/O Ocular injury.
• No H/o-recent ophthalmic consultation.

4. CONT….
Past History-
No relevant history
Family History-
No relevant history

5. OCULAR EXAMINATION
RIGHT EYE (OD) LEFT EYE (OS)
UNAIDED VA-
DISTANCE &
NEAR VISION
20/20
N.6
20/20
N.6
RETINOSCOPY
ACCEPTANCE
-0.75D SPH -0.75D SPH
IOP 10.0 MM OF Hg 10.0 MM OF Hg
OCULAR
MOTILITY
PAINLESS, FULL,
FREE
PAINLESS, FULL,
FREE

6. CONT….
RIGHT EYE (OD) LEFT EYE (OS)
LIDS MILD EDEMA MILD EDEMA
CONJUNCTIVA CONGESTION,
PAPILLAE 2+3
CONGESTION,
PAPILLAE 2+3
CORNEA

7. (OU)

8. CONT….
RIGHT EYE(OD) LEFT EYE (OS)
AC DEEP DEEP
IRIS WNL WNL
PUPIL R/R/R R/R/R
LENS CLEAR CLEAR
FUNDUS C:D 0.3:1, HNRR,
RETINA ON
C:D 0.3:1, HNRR,
RTINA ON

9. CON…
• Differential diagnosis :

10. DIAGNOSIS
• (OU) VERNAL KERATOCONJUNCTIVITIS
ADV :
1) Loteprednol eye drop 4/3/2/1
2) olopatadine + ketorolac eye drop bd
3) carboxymethyl cellulose 1% eye drop qid
RTC:- 1M

11. REVIEW 1 MONTH
• Comfortable
• VISUAL ACUITY- OD- 20/20, OS- 20/20
• SLE(OU)
Lid-Flat
Conjunctiva-congestion,papillae
Cornea - spk,s
• IOP- 10 mm Hg (OD) 10 mm Hg (OS)
• Imp :Better
• Adv : Fluorometholone acetate e/d OD,A/D
olopatadine + ketorolac eye drop bd
carboxymethyl cellulose 1% eye drop qid
• RTC:1M

12. REVIEW 1 MONTH
• Comfortable
• VISUAL ACUITY- OD- 20/20, OS- 20/20
• SLE(OU)
Lid-flat
Conjunctiva-quiet
Cornea –few spk,s
• IOP- 14 mm Hg (OD) 10 mm Hg (OS)
• Imp :D/W
• Adv :Fluorometholone acetate e/d OD ×2M
Acupat e/d 1 times/day ×2W
Refresh teears e/d 6 times/day ×2M
•
• RTC:2M

13. CON…
Discussion

14. VERNAL
KERATOCONJUNCTIVITIS
-Vernal keratoconjunctivitis (VKC) is a
chronic,
bilateral,
at times asymmetrical,
seasonally exacerbated,
allergic inflammation of the ocular surface,
involving tarsal and ⁄ or bulbar conjunctiva.
-Its exact aetiology and pathogenesis is still unclear.

15. PREVALENCE
- More common in temperate zones of Mediterranean areas.
central and west Africa, the Middle East, Japan, the Indian
subcontinent and South America.
- After the recent decline of endemic trachoma, VKC is a leading
cause of outpatient ophthalmic morbidity.

16. AGE, GENDER, GENETICS AND
ASSOCIATED DISEASES
-Starts before 10 years. (The earliest reported age is 5 months
-Resolves after puberty, usually around 4–10 years .
• Male to female ratio - varying from 4:1 to 2:1
• One third of VKC patients have multiple atopic diseases.
• In a gender- and age-matched study, a positive correltion between
eyelash length and severity of VKC has been reported.

17. SYMPTOMS
- Pruritus,
- Hyperaemia,
- Photophobia and
- Watering,
 Initially seasonal may become perennial after a few years.
• Exacerbated by exposure to wind, dust, bright light, hot
weather or physical exertion associated with sweating.

18. SIGNS
-Thick mucus hyper-secretion with sticky mucous filaments,
called ‘ropy discharge’, is a characteristic of VKC.
-Transient limbal or conjunctival yellow-white points or deposits,
known as Horner–Trantas’s dots are degenerating eosinophils
and epithelial cell debris.
-The extent of pigmentation did not correlate with the severity of
symptoms and signs of VKC.
-The pigmentation persisted when the disease was inactive

19. SIGNS
Limbal Papillae, Horner-Tranta’s Dots, Cobble stone Papillae

20. SIGNS : PAPILLAE
1) Papillae :
- Large (> 1 mm) papillae in VKC occur at the upper tarsus.
- Size of 7–8 mm are known as cobble- stone papillae.
- Papillae size correlate positively with the persistence or
worsening of symptoms over long-term follow-up .
- Papillae become quite swollen during the active stage but persist
even during the quiescent stage.
- Limbal papillae tend to be gelatinous and confluent.

21. SIGNS:PAPILLAE GRADING
Grade 0: no papillary reaction.
Grade 1+: few papillae, 0.2 mm widespread over the tarsal
conjunctiva or around the limbus.
Grade 2+: papillae of 0.3–1 mm over the tarsal conjunctiva or at
the limbus.
Grade 3+: papillae of 1–3 mm all over the tarsal conjunctiva for
360° around the limbus.
Grade 4+: papillae of more than 3 mm over the tarsal conjunctiva
or gelatinous appearance at the limbus covering the peripheral
cornea.

22. CLASSIFICATION AND CORNEAL CHANGES OF VKC
-Palpebral, bulbar or mixed type
-Corneal changes:
-punctate epithelial keratitis,
-epithelial macroerosions,
-Shield ulcer,
- plaque formation and
- late corneal vascularization .
-Coalescence of punctate epithelial keratitis areas leads to frank
corneal epithelial erosion, leaving Bowman’s membrane intact.

23. OTHER SIGNS IN VKC
2) Pseudogerontoxon - resembles arcus senilis,
-a waxing and waning grey-white lipid deposition in the
superficial stroma of the peripheral cornea.
3)The skin of the lid and lid margin may be thick and lax.
4)Amblyopia seen among VKC may be caused by corneal opacity,
irregular astigmatism.
5) Keratoconus.
6) Dry eye syndrome,
7) Cataract and glaucoma caused by unsupervised use of topical
corticosteroids .

24. Treatment

25. General measures
1. Allergen avoidance,
2. Cool compresses
3 .Lid hygiene

26. Local treatment
1.Mast cell stabilizers:
-reduce the frequency of acute exacerbations
-In some patients adding a NSAID (ketorolac, diclofenac)
may give added benefit

27. CON..
2 .Antihistamines
-for acute exacerbations but generally not for long-term use.
3.Combined preparations of an antihistamine and a
vasoconstrictor usually offer only limited relief whereas dual
action antihistamine/mast cell stabilizers are often effective.

28. Immune modulators
a. Ciclosporin 0.05% b.d.
-indicated if steroids are ineffective, inadequate or poorly
tolerated, or as a steroid-sparing agent in patients with severe
disease.
- The drug may cause ocular irritation and blurred vision
b.Tacrolimus 0.03% ointment
- effective in VKC for severe eyelid disease.
- Instillation into the fornices has been effective in modulating
conjunctival inflammation in refractory cases

29. Other measures
a.Antibiotics are used in conjunction with steroids in severe
keratopathy to prevent or treat bacterial infection.
B.Acetylcysteine :
-a mucolytic agent that is useful in VKC for dissolving
mucus filaments and deposits, and addressing early plaque
formation

30. Systemic treatment
1.Antihistamines
used to reduce itching,
promote sleep and
reduce nocturnal eye rubbing
2 .Antibiotics (doxycycline 50–100 mg daily for 6 weeks or
azithromycin 500 mg once daily for 3 days) to reduce
blepharitis-aggravated inflammation, usually in AKC

31. CON..
• Immunosuppressive agents (e.g. steroids, ciclosporin,
tacrolimus, azathioprine)
- effective at relatively low doses,unresponsive to other
measures.
-Short courses of high-dose steroids may be necessary to achieve
rapid control in severe disease.
- Monoclonal antibodies against T cells have shown some
promise in refractory cases.
4.Aspirin: useful in VKC, although the risk of Reye's syndrome
means it should be avoided in children and adolescents (the group
predominantly affected by VKC).

32. Surgery
1. Bandage contact lens wear may be appropriate to aid the
healing of persistent epithelial defects.
2. Superficial keratectomy:
- required to remove plaques or debride shield ulcers and
allow epithelialization.
- Medical treatment must be maintained until the cornea
has re-epithelialized in order to prevent recurrences.
- Excimer laser phototherapeutic keratectomy is an
alternative.

33. CON…
• Surface maintenance-restoration surgery:
- such as amniotic membrane overlay grafting or
- lamellar keratoplasty, or
• eyelid procedures such as
- botulinum toxin-induced ptosis or lateral tarsorrhaphy, may be
required for severe persistent epithelial defects or ulceration.
- Gluing may be appropriate for focal (‘punched-out’) corneal
perforations.

34. CON..
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