Diagnosis, Management, and Treatment of Vernal Keratoconjunctivitis in Asia: Recommendations From the Management of Vernal Keratoconjunctivitis in Asia Expert Working Group

Abstract

Vernal keratoconjunctivitis (VKC) is an underdiagnosed and underrecognized ocular surface disease with limited epidemiological data in Asia. It is more prevalent in warm, dry, and windy climates, and often has a substantial impact on a patient's quality of life. In rare cases, VKC can be associated with vision loss, either through corticosteroid overuse or inadequate treatment of persistent inflammation. As a potentially severe and complex disease, there is variability with how VKC is managed across Asia and among the various allergic eye diseases. Diagnosis and treatment of patients with VKC is a challenge for many ophthalmologists, since no precise diagnostic criteria have been established, the pathogenesis of the disease is unclear, and anti-allergic treatments are often ineffective in patients with moderate or severe disease. In addition, the choice of treatment and management strategies used for patients varies greatly from country to country and physician to physician. This may be because of a lack of well-defined, standardized guidelines. In response, the Management of Vernal Keratoconjunctivitis in Asia (MOVIA) Expert Working Group (13 experts) completed a consensus program to evaluate, review, and develop best-practice recommendations for the assessment, diagnosis, and management of VKC in Asia. The expert-led recommendations are summarized in this article and based on the currently available evidence alongside the clinical expertise of ophthalmologists from across Asia with specialism and interest in the ocular surface, VKC, and pediatric ophthalmology.

Keywords: MOVIA; consensus; corticosteroids; cyclosporine A (CsA); ocular allergy; ocular surface; recommendations (guidelines); vernal keratoconjunctivitis (VKC).

FIGURE 1

A new paradigm for the stepwise management of VKC based on disease severity. Adapted from Leonardi et al. (28). *In the case of associated rhinitis, consider treatment according to Allergic Rhinitis and its Impact on Asthma (ARIA) protocol; ^†No improvement is defined as no improvement in symptoms or changes in conjunctival, papillary or ocular surface clinical signs. CE, cationic emulsion; CsA, cyclosporine A; IgE, immunoglobulin E.

FIGURE 2

Clinical subtypes of VKC: Tarsal form. The tarsal form is characterized by large, cobblestone-like papillae on the upper tarsal conjunctiva. (A) Image courtesy of Jodhbir S. Mehta; (B) image courtesy of Douglas K. Lam.

FIGURE 3

Clinical subtypes of VKC: Limbal form. The limbal form typically involves Horner–Trantas dots (see Figure 5), indicating lymphocytic and eosinophilic infiltration of the limbal conjunctiva. The mixed form is characterized by the presence of both tarsal and limbal subtypes in only one eye. (A) Image courtesy of Wei-Li Chen; (B–D) images courtesy of Jodhbir S. Mehta; (E) image courtesy of Florence Manurung.

FIGURE 4

Patients with shield ulcer formation. Shield ulcers usually form on the upper third of the cornea. Plaques can also form when inflammatory debris accumulates at the base of a shield ulcer. (A) Image courtesy of Ramesh Kekunnaya; (B,C) images courtesy of Wei-Li Chen; (D) image courtesy of Leo Seo Wei; (E) image courtesy of Dominique Bremond-Gignac.

FIGURE 5

Horner–Trantas dots. Peri-limbal Horner–Trantas dots are focal white dots consisting of degenerated epithelial cells and eosinophils and are indicative of VKC. (A) Image courtesy of Florence Manurung; (B) image courtesy of Leo Seo Wei; (C) image courtesy of Dominique Bremond-Gignac.

FIGURE 6

Large cobblestone papillae. Upper tarsal giant papillae are typical of VKC. These have characteristically flattened tops which sometimes demonstrate stain with fluorescein. Giant papillae can sometimes be seen near the limbus and, while relatively uncommon, symblepharon formation and conjunctival fibrosis can occur. (A–D) Images courtesy of Florence Manurung; (E) image courtesy of Douglas K. Lam; (F) image courtesy of Jodhbir S. Mehta; (G) image courtesy of Wei-Li Chen; (H-I) images courtesy of Leo Seo Wei.

FIGURE 7

Characteristic papillary hyperplasia in VKC. The conjunctiva often shows hyperplasia, with infiltration of lymphocytes and eosinophils. (A) Image courtesy of Wei-Li Chen; (B) image courtesy of Jodhbir S. Mehta; (C) image courtesy of Dominique Bremond-Gignac.

FIGURE 8

Levels of severity of VKC, based on the Bonini grading scale. Adapted from Bonini et al. (27). Images courtesy of Dominique Bremond-Gignac. SPK, superficial punctate keratopathy.