March 2021


Handling vernal conjunctivitis

by Ellen Stodola Editorial Co-Director


Vernal keratoconjunctivitis (VKC) is a condition that usually presents in young children. It is one of the less common forms of allergic conjunctivitis, however, it arguably has some of the most significant and serious signs and symptoms, according to Victor Pegado, MD.
Although it can present in adults, VKC is almost always specific to children, Dr. Pegado said. VKC usually occurs between 4 years of age and adolescence.
Dr. Pegado said children with this condition are often suffering and have light sensitivity (photophobia), sometimes coming in wearing a hat and sunglasses. “These are the ones you remember and you feel for,” he said, adding it’s important to try to treat them as best as possible. Although you can’t “cure” them, you can alleviate their symptoms and make life more manageable.
According to Dr. Pegado, by the time they see an ophthalmologist, these patients have usually seen a number of other caregivers. They may have been treated by the family doctor for simple allergy, or an optometrist may have treated them with antihistamines, he said, adding that these patients tend to have chronic symptoms throughout the year, but it gets worse for them in the spring. These children usually present with extreme light sensitivity, pain, and won’t open their eyes at all. These symptoms are consistent with moderate to severe VKC and are caused by keratitis occurring secondary to mechanical trauma from the eyelid combined with immune-related damage on a cellular level.
The incidence changes depending on location, Dr. Pegado said. In Mediterranean areas, India, and Africa, the incidence is higher, but in Europe and North America, it’s about 1–10 per 10,000.
“With many of these inflammatory or allergic conditions, we tend to use a stepwise approach,” he said. Every patient needs to start with moderating the environment and trying to avoid triggers, he added. These children also tend to have a history of asthma. Artificial tears can be used, cold compresses help minimize eye rubbing, and lid scrubs can remove allergens, Dr. Pegado said.
Then you can move on to antihistamines, he said. If symptoms are severe and the patient has keratitis or visually threatening signs or if he or she cannot function because of photophobia and discomfort, sometimes steroids or immunomodulating agents are required. “With children, we try to avoid chronic steroids because we’re worried about the risk of cataract and glaucoma,” Dr. Pegado said. Pulsed steroids, infrequently over a short period of time, can be used with a goal of trying to stop them as fast as possible.
Dr. Pegado shared a case that stood out to him of a boy who presented at age 6. He came into the office with sunglasses on and a baseball cap to block the light. He had more of an eyelid problem with giant palpebral papillae with severe keratitis and punctate epithelial erosions throughout the cornea. He was extremely photophobic.
Topical steroids helped him improve, Dr. Pegado said, and he was given a dual-action agent to use all the time. “When you treat these patients, it’s not usually one treatment,” he said. “They get dual-action agents and may use artificial tears on top of that.”
After several courses of topical steroids, with different types and escalating strengths, Dr. Pegado was able to get his condition under control.
The next year, the boy presented with a shield ulcer, which is another classic sign of VKC. It took a long time for the shield ulcer to resolve, and the patient was put on topical cyclosporine. This ended up being the treatment he needed, Dr. Pegado said, noting that the boy’s mother contacted him to say the medication was working and it “changed his life.” This became a simpler treatment, with one agent to use four times daily during allergy season, and it controlled his symptoms.

About the physician

Victor Pegado, MD

Clinical Assistant Professor
Department of Ophthalmology & Visual Sciences
The University of British Columbia
Victoria, British Columbia, Canada

Relevant disclosures

: None



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