Vernal keratoconjunctivitis: Management and outlook

Symptoms of VK

The most common symptoms of vernal keratoconjunctivitis are:

• redness
• intense itching
• a sensation of having a foreign body in the eye
• watery eyes
• thick, ropy mucus discharge, particularly upon waking
• blurred vision
• sensitivity to light, called photophobia

Symptom flare-ups typically occur in warm weather or can be present year-round, particularly in tropical areas.

People who experience symptoms of VK should consult a doctor. Following a diagnosis of VK, a person can begin treatment to help alleviate symptoms and prevent permanent eye damage.

Causes and risk factors

Below are the causes of VK and the risk factors for developing the disease.

Causes

Vernal keratoconjunctivitis occurs when inflammatory cells infiltrate the conjunctiva of the eye. These inflammatory cells include:

• eosinophils
• activated CD4+ lymphocytes
• cytokines

Risk factors

Vernal keratoconjunctivitis is more common in people who have pre-existing allergies and those who have a family history of one or more of the following:

• allergic rhinitis
• atopic dermatitis
• asthma

Exposure to the following environmental allergens can also increase the likelihood of VK:

• pet dander
• molds
• pollens
• tobacco smoke

People with VK should try to avoid allergens that trigger symptoms. They should also consider washing their hands frequently and avoid touching or rubbing their eyes.

Dry, hot climates can also contribute to VK. People with the condition can help reduce flare-ups by staying inside on hot days or wearing sunglasses to protect the eyes.

Managing VK

The treatment for VK depends on the severity of the disease. Clinicians propose a stepwise approach to treatment that focuses on the following:

• preventing flare-ups of the condition
• alleviating symptoms
• reducing inflammation
• preventing irreversible damage to the cornea and associated vision loss

The following treatments may be beneficial during all stages of the disease:

• cold compresses
• eye lubricants
• lid scrubs

Managing VK according to severity

Doctors will prescribe VK treatments according to the severity of the disease. Below are some treatment options for mild, moderate, and severe VK.

Mild VK

To alleviate itching, doctors may prescribe topical antihistamines, such as levocabastine and emedastine.

Some people use lubricating eye medications, such as artificial tears, gels, or ointments. These medications are suitable adjunctive treatments for mild VK, but they are often less effective as a standalone treatment.

Topical over-the-counter (OTC) decongestant eye drops have limited effectiveness in treating VK. This is because they do not reduce the allergic response and can cause rebound congestion.

Moderate VK

Doctors may prescribe one or more of the following treatments for moderate VK:

Mast cell stabilizers

Doctors may prescribe topical mast cell stabilizers. These agents help reduce histamine release from cells called “mast cells,” thereby reducing eye inflammation, redness, and itching.

Examples of mast cell stabilizers include:

• cromolyn
• lodoxamide
• pemirolast

Dosing is two to six times daily. A response can take 2 weeks to occur.

Dual activity topical antihistamine/mast cell stabilizers

Dual activity topical antihistamine/mast cell stabilizers are also available. Agents include:

• alcaftadine
• azelastine
• bepotastine
• epinastine
• ketotifen
• olopatadine

Dosing is one to four times daily. These combination products provide immediate relief from symptoms. However, the antihistamine component may have a drying effect on the eye, making symptoms worse.

Nonsteroidal anti-inflammatory drugs

There is clinical evidence to suggest that the nonsteroidal anti-inflammatory drugs (NSAIDs) diclofenac and ketorolac are effective in treating VK. Doctors may prescribe the drugs for rapid symptom relief. However, they are not suitable for long-term use due to their potential to cause corneal toxicity.

Doctors will avoid prescribing NSAIDs in people who already have corneal involvement.

The dosing of NSAIDs is four times daily.

Topical corticosteroids

Doctors may prescribe topical corticosteroids to reduce inflammation of the eye. Typically, they will begin by prescribing these drugs in high doses and quickly taper the dosage off. Dosing is two to four times daily.

Topical corticosteroid agents include:

• dexamethasone
• fluorometholone
• loteprednol
• prednisolone
• rimexolone

Applying topical corticosteroids to the eye can cause side effects, such as cataracts and glaucoma. As such, people should use the lowest dose possible for the shortest period necessary to control symptoms.

Severe VK

Immunomodulators are drugs that help modify the function of the immune system. A 2018 review of VK notes that the immunomodulator cyclosporine may help alleviate some symptoms of VK.

According to the review, the side effects of cyclosporine are less severe than those of corticosteroids. A doctor may prescribe the two treatments in combination, where necessary.

A 2019 review of cyclosporine for severe VK explores the various strengths, dosages, and formulations of the drug necessary to control the symptoms of the disease. These factors are still under clinical investigation.

Resistant cases of VK, or those with corneal involvement, may require treatment with one or more of the following:

• oral corticosteroids
• oral cyclosporine
• allergen-specific immunotherapy
• monoclonal antibodies (omalizumab)
• surgery to remove corneal plaques

How do doctors diagnose VK?

To diagnose VK, a doctor will begin by:

• taking a detailed medical history
• asking about a person’s symptoms and when they started
• conducting a physical examination

To help determine the cause of conjunctivitis, the doctor will ask about the following:

• contact lens use
• exposure to chemicals
• contact with people who have an active eye infection

A doctor can confirm a diagnosis of VK by inspecting the conjunctiva for signs of the following:

• Papillae: These are pimple-like projections that can vary in size, with large papillae taking on a cobbled appearance.
• Trantas dots: These are chalky-white nodules that appear on the edges of the conjunctiva.

A doctor can also assess if there is any corneal involvement, such as corneal ulcers or plaques.

Doctors can differentiate VK from other types of allergic conjunctivitis because VK does not affect the eyelid margin.

Grading systems are available to help doctors rate the severity of the disease and guide treatment.

Will VK go away?

VK usually starts in early childhood, and most cases resolve after puberty. Appropriate treatment can prevent complications, such as:

• ulcers
• cataracts
• glaucoma
• vision loss, which occurs in approximately 6% of people

Around 12% of people who develop VK in childhood continue to experience symptoms into adulthood. Medical professionals then refer to the condition as “atopic keratoconjunctivitis.” The treatment is similar to that for VK.

Summary

Vernal keratoconjunctivitis (VK) is an inflammatory eye condition that can affect both the conjunctiva and cornea of the eye. It is usually caused by exposure to allergens.

Vernal keratoconjunctivitis usually develops in childhood, and most cases resolve after puberty. However, some people continue to experience the disease into adulthood.

People who experience symptoms of VK should see their doctor as soon as possible for a diagnosis and appropriate treatment. Prompt treatment can help alleviate inflammation and reduce the risk of permanent eye damage.