Vernal keratoconjunctivitis (VKC), also known as spring catarrh, is a recurrent allergic inflammation of the conjunctiva that predominantly affects children and adolescents. It is caused by a hypersensitivity reaction to environmental allergens like pollen. Clinically, it presents as papillae on the tarsal conjunctiva (palpebral form), limbal lesions (bulbar form), or a combination of both. Treatment involves topical steroids, mast cell stabilizers, and antihistamines to control inflammation and symptoms like itching. Severe cases may require oral steroids or surgical excision of large papillae. The condition typically resol

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Compiled by; Dr. Iddi Ndyabawe
VERNAL KERATOCONJUNCTIVITIS (VKC) OR
SPRING CATARRH
It is a recurrent, bilateral, interstitial, self-limiting, allergic inflammation of the conjunctiva
having a periodic seasonal incidence.
Etiology
It is considered a hypersensitivity reaction to some exogenous allergen, such as grass pollens.
VKC is thought to be an atopic allergic disorder in many cases, in which IgE-mediated
mechanisms play an important role. Such patients may give personal or family history of other
atopic diseases such as hay fever, asthma, or eczema and their peripheral blood shows
eosinophilia and inceased serum IgE levels.
Predisposing factors
1. Age and sex. 4-20 years; more common in boys than girls.
2. Season. More common in summer; hence the name spring catarrh looks a misnomer. Recently
it is being labelled as 'Warm weather conjunctivitis'.
3. Climate. More prevalent in tropics, less in temperate zones and almost non-existent in cold
climate.
Pathology
1. Conjunctival epithelium undergoes hyperplasia and sends downward projections into the
subepithelial tissue.
2. Adenoid layer shows marked cellular infiltration by eosinophils, plasma cells, lymphocytes
and histiocytes.
3. Fibrous layer shows proliferation which later on undergoes hyaline changes.
4. Conjunctival vessels also show proliferation, increased permeability and vasodilation.
All these pathological changes lead to formation of multiple papillae in the upper tarsal
conjunctiva.
Clinical picture
Symptoms. Spring catarrh is characterised by marked burning and itching sensation which is
usually intolerable and accentuated when patient comes in a warm humid atmosphere. Itching is
more marked with palpebral form of disease.
Other associated symptoms include: mild photophobia, lacrimation, stringy (ropy) discharge

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and heaviness of lids.
Signs of vernal keratoconjunctivitis can be described in following three clinical forms:
1. Palpebral form. Usually upper tarsal conjunctiva of both eyes is involved.
The typical lesion is characterized by the presence of hard, flat topped, papillae arranged in a
'cobble-stone' or 'pavement stone', fashion.
In severe cases, papillae may hypertrophy to produce cauliflower like
excrescences of 'giant papillae'.
Conjunctival changes are associated with white ropy discharge.
2. Bulbar form. It is characterised by:
(i) dusky red triangular congestion of bulbar conjunctiva in palpebral area;
(ii) gelatinous thickened accumulation of tissue around the limbus; and
(iii) presence of discrete whitish raised dots along the limbus (Tranta's spots)
3. Mixed form. It shows combined features of both palpebral and bulbar forms.
Vernal keratopathy.
Corneal involvement in VKC may be primary or secondary due to extension of limbal lesions.
Vernal keratopathy includes following 5 types of lesions:
1. Punctate epithelial keratitis involving upper cornea is usually associated with palpebral form
of disease. The lesions always stain with rose bengal and invariably with fluorescein dye.
2. Ulcerative vernal keratitis (shield ulceration) presents as a shallow transverse ulcer in upper
part of cornea. The ulceration results due to epithelial macroerosions. It is a serious problem
which may be complicated by bacterial keratitis.
3. Vernal corneal plaques result due to coating of bare areas of epithelial macroerosions with a
layer of altered exudates.
4. Subepithelial scarring occurs in the form of a ring scar.
5. Pseudogerontoxon is characterised by a classical ‘cupid’s bow’ outline.

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Clinical course of disease is often self-limiting and usually burns out spontaneously after 5-10
years.
Differential diagnosis. Palpebral form of VKC needs to be differentiated from trachoma with
pre-dominant papillary hypertrophy
Treatment
A. Local therapy
1. Topical steroids. These are effective in all forms of spring catarrh.
However, their use should be minimised, as they frequently cause steroid induced glaucoma.
Therefore, monitoring of intraocular pressure is very important during steroid therapy.
Frequent instillation (4 hourly) to start with (2 days) should be followed by maintenance therapy
for 3-4 times a day for 2 weeks.
Commonly used steroid solutions are of fluorometholone medrysone, betamethasone or
dexamethasone. Medrysone and fluorometholone are safest of all these.
2. Mast cell stabilizers such as sodium cromoglycate (2%) drops 4-5 times a day are quite
effective in controlling VKC, especially atopic cases. It is mast cell stabilizer. Azelastine eye
drops are also effective in controlling VKC.
3. Topical antihistaminics are also effective.
4. Acetyl cysteine (0.5%) used topically has mucolytic properties and is useful in the treatment of
early plaque formation.
5. Topical cyclosporine (1%) drops have been recently reported to be effective in severe
unresponsive cases.
B. Systemic therapy
1. Oral antihistaminics may provide some relief from itching in severe cases.
2. Oral steroids for a short duration have been recommended for advanced, very severe,
nonresponsive cases.
C. Treatment of large papillae. Very large (giant) papillae can be tackled either by :
Supratarsal injection of long acting steroid or Cryo application
Surgical excision is recommended for extraordinarily large papillae.

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D. General measures include :
Dark goggles to prevent photophobia.
Cold compresses and ice packs have soothing effects.
Change of place from hot to cold area is recommended for recalcitrant cases.
E. Desensitization has also been tried without much rewarding results.
F. Treatment of vernal keratopathy
Punctate epithelial keratitis requires no extra treatment except that instillation of steroids should
be increased.
A large vernal plaque requires surgical excision by superficial keratectomy.
Severe shield ulcer resistant to medical therapy may need surgical treatment in the form of
debridement, superficial keratectomy, excimer laser therapeutic keratectomy as well as amniotic
membrane transplantation to enhance reepithelialization.