Key words: classification, etiology, pathology, clinical manifestations, diagnosis, treatment, prognosis

1. Vernal Conjunctivitis
Prof Ariyanto Harsono MD PhD SpA(K)

2. Introduction
Vernal conjunctivitis is chronic inflammation of the outer
lining of the eyes.
Is also called Vernal keratoconjunctivitis (VKC)
interchangealy is a member of a group of diseases
classified as allergic conjunctivites including perennial and
seasonal rhinoconjunctivitis, atopic keratoconjunctivitis,
and giant papillary conjunctivitis. Vernal conjunctivities
were considered the expression of a classical type I IgE-mediated
hypersensitivity reaction at the conjunctival
level. More recent clinical observations, however, suggest
that other tissues of the eye are also involved in the
ocular allergic reaction.
Prof Ariyanto Harsono MD PhD SpA(K) 2

3. New discoveries regarding the pathogenesis of
ocular allergies have clearly indicated that the
participation of the entire ocular surface in allergic
diseases is not only the consequence of tissue
contiguity but derives from a complex exchange of
information between these tissues through cell-to-cell
communications, chemical mediators,
cytokines, and adhesion molecules.
Prof Ariyanto Harsono MD PhD SpA(K) 3

4. Allergic conjunctivitis subtypes
Vernal Conjunctivitis belongs to Allergic conjunctivitis group.
Allergic conjunctivitis may be divided into 5 major subcategories.
 Seasonal allergic conjunctivitis (SAC) and perennial allergic
conjunctivitis (PAC) are commonly grouped together.
 Vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis
(AKC), and giant papillary conjunctivitis (GPC) constitute the
remaining subtypes of allergic conjunctivitis.
Early diagnosis and treatment will help prevent the rare
complications that can occur with this disease.
Prof Ariyanto Harsono MD PhD SpA(K) 4

5. Etiology
VKC is thought to be an allergic disorder in which
IgE mediated mechanism play a role. Such patients
often give family history of other atopic diseases
such as hay fever, asthma or eczema, and their
peripheral blood shows eosinophilia and increased
serum IgE levels.
Prof Ariyanto Harsono MD PhD SpA(K) 5

6. Predisposing Factors
Age and sex – 4–20 years; more common in boys
than girls.
Season – More common in summer. Hence, the
name Spring catarrh is a misnomer. Recently it is
being labelled as Warm weather conjunctivitis.
Climate – More prevalent in the tropics. VKC cases
are mostly seen in hot months of summer,
therefore, more suitable term for this condition is
"summer catarrh".
Prof Ariyanto Harsono MD PhD SpA(K) 6

7. Pathology
Conjunctival epithelium undergoes hyperplasia and
sends downward projection into sub-epithelial
tissue.
Adenoid layer shows marked cellular infiltration
by eosinophils, lymphocytes, plasma
cells and histiocytes.
Fibrous layer show proliferation which later
undergoes hyaline changes.
Conjunctival vessels also show proliferation,
increased permeability and vasodilation.
Prof Ariyanto Harsono MD PhD SpA(K) 7

8. Clinical Manifestations
Symptoms- VKC is characterized by marked burning and itchy
sensations which may be intolerable and accentuates when patient
comes in a warm humid atmosphere. Associated symptoms include
mild photophobia, lacrimation, stringy discharge and heaviness of
eyelids.
Signs of VKC can be described in three clinical forms.
 Palpebral form- Usually upper tarsal conjunctiva of both the eyes
is involved. Typical lesion is characterized by the presence of
hard, flat-topped papillae arranged in cobblestone or pavement
stone fashion. In severe cases papillae undergo hypertrophy to
produce cauliflower-like excrescences of 'giant papillae'.
 Bulbar form- It is characterized by dusky red triangular
congestion of bulbar conjunctiva in palpebral area, gelatinous
thickened accumulation of tissue around limbus and presence of
discrete whitish raised dots along the limbus (Tranta's spots).
 Mixed form- Shows the features of both palpebral and bulbar
types. Prof Ariyanto Harsono MD PhD SpA(K) 8

9.  Burning eyes
 Discomfort in bright light
(photophobia)
 Itching eyes
 The area around the cornea
where the white of the eye and
the cornea meet (limbus) may
become rough and swollen
 The inside of the eyelids (most
often the upper ones) may
become rough and covered with
bumps and a white mucus
 Watering eyes
Prof Ariyanto Harsono MD PhD SpA(K) 9

10. VKC may be subdivided into 2
varieties, as follows: palpebral and
limbal. The classic conjunctival
sign in palpebral VKC is the
presence of giant papillae. The
papillae most commonly occur on
the superior tarsal conjunctiva;
usually, the inferior tarsal
conjunctiva is unaffected. Giant
papillae assume a flattop
appearance, which often is
described as "cobblestone
papillae." In severe cases, large
papillae may cause mechanical
ptosis (drooping eyelid).
Prof Ariyanto Harsono MD PhD SpA(K) 10

11. Diagnosis
1. In seasonal and perennial allergic conjunctivitis, superficial
conjunctival scrapings may help to establish the diagnosis
by revealing eosinophils, but only in the most severe cases,
since eosinophils are typically present in the deeper layers
of the substantia propria of the conjunctiva. Therefore, the
absence of eosinophils on conjunctival scraping does not
rule out the diagnosis of allergic conjunctivitis.
2. Many investigators have described measurement of tear
levels of various inflammatory mediators, such as IgE,
histamine, and tryptase, as indicators of allergic activity.
Prof Ariyanto Harsono MD PhD SpA(K) 11

12. 3. Additionally, skin testing by an
allergist may provide definitive
diagnosis and pinpoint the offending
allergen(s).
Prof Ariyanto Harsono MD PhD SpA(K) 12

13. In vernal keratoconjunctivitis (VKC), conjunctival
scrapings of the superior tarsal conjunctiva and of
Horner-Trantas dots show an abundance of
eosinophils. Conjunctival scrapings of patients with
atopic keratoconjunctivitis (AKC) may demonstrate
the presence of eosinophils, although the number is
not as significant as that seen in VKC. Additionally,
free eosinophilic granules, which are seen in VKC,
are not seen in AKC.
Prof Ariyanto Harsono MD PhD SpA(K) 13

14. Treatment
Local therapy
Topical steroids are effective. Commonly used solutions are
fluorometholone, betamethasone or dexamethasone.
Mast cell stabilizers such as sodium cromoglycate (2%) drops 4–5
times a day. Common mast cell stabilizers include cromolyn sodium
and lodoxamide. Alcaftadine, olopatadine, nedocromil, and ketotifen
are mast cell stabilizers and inhibit histamine release.
Azelastine eyedrops are also effective.
Artificial tears substitutes provide a barrier function and help to
improve the first-line defense at the level of conjunctival mucosa.
These agents help to dilute various allergens and inflammatory
mediators that may be present on the ocular surface, and they help
flush the ocular surface of these agents.
Acetyl cysteine (.0.5%) used topically has mucolytic properties and
is useful in the treatment of early plaque formation.
Topical Cyclosporine is reserved for unresponsive cases.
Prof Ariyanto Harsono MD PhD SpA(K) 14

15. Systemic therapy
Oral antihistamines and oral steroids for severe cases.
Treatment of large papillae- Cryo application, surgical
excision or supratarsal application of long-acting steroids.
Vasoconstrictors are available either alone or in conjunction
with antihistamines to provide short-term relief of vascular
injection and redness. Common vasoconstrictors include
naphazoline, phenylephrine, oxymetazoline, and
tetrahydrozoline. Generally, the common problem with
vasoconstrictors is that they may cause rebound conjunctival
injection and inflammation. These pharmacologic agents are
ineffective against severe ocular allergies and against other
more severe forms of allergic conjunctivitis, such as atopic and
vernal disease.
Prof Ariyanto Harsono MD PhD SpA(K) 15

16. Corticosteroids
o Corticosteroids remain among the most potent pharmacologic
agents used in the treatment of chronic ocular allergy. They act at
the first step of the arachidonic acid pathway by inhibiting
phospholipase, which is responsible for converting membrane
phospholipid into arachidonic acid.
o Corticosteroids do have limitations, including ocular adverse
effects, such as
 delayed wound healing,
 secondary infection,
 elevated intraocular pressure, and
 formation of cataract.
In addition, the anti-inflammatory and immunosuppressive affects
are nonspecific. As a rule, topical steroids should be prescribed
only for a short period of time and for severe cases that do not
respond to conventional therapy.
Prof Ariyanto Harsono MD PhD SpA(K) 16

17. General measures include use of dark goggles to
prevent photophobia, cold compresses and ice pack for
soothing effects, change of place from hot to cold areas.
Desensitization has also been tried without much
rewarding results.
Treatment of vernal keratopathy- Punctuate epithelial
keratitis require no extra treatment except that
instillation of steroids should be increased.
Large vernal plaque requires surgical excision.
Ulcerative vernal keratitis require surgical treatment in
the form of debridement, superficial keratectomy,
excimer laser therapeutic keratectomy, as well as
amniotic membrane transplantation to enhance re-epithelialisation.
Prof Ariyanto Harsono MD PhD SpA(K) 17

18. Home care measures
Avoid rubbing the eyes, because this can
irritate them more.
Cold compresses (a clean cloth soaked in cold
water and then placed over the closed eyes)
may be soothing.
Lubricating drops may also help soothe the
eye.
Prof Ariyanto Harsono MD PhD SpA(K) 18

19. Immunotherapy
Immunotherapy is a mainstay in the systemic
management of allergies. Traditionally,
immunotherapy is delivered via subcutaneous
injection. However, sublingual (oral)
immunotherapy (SLIT) is gaining momentum
among allergists. Numerous articles have analyzed
the effects of SLIT on allergic conjunctivitis. SLIT
may significantly reduce symptoms in children with
grass pollen–allergic rhinoconjunctivitis.
Prof Ariyanto Harsono MD PhD SpA(K) 19

20. Differential Diagnoses
Conjunctivitis, Bacterial
Conjunctivitis, Giant Papillary
Conjunctivitis, Viral
Keratoconjunctivitis, Atopic
Keratoconjunctivitis, Superior Limbic
Keratoconus
Prof Ariyanto Harsono MD PhD SpA(K) 20

21. Prevention
Seasonal and perennial allergic conjunctivitis
 Avoidance of the offending antigen is the primary behavioral modification;
specific testing by an allergist will identify the responsible allergen(s) and
help the individual to establish ways to avoid the allergen. Contact reactions
caused by medications or cosmetics are also treated best by avoidance.
Vernal keratoconjunctivitis
 As with most type I hypersensitivity disorders, allergen avoidance should be
emphasized as the first-line treatment. Although permanent relocation to a
cooler climate is not feasible in many cases, it remains a very effective
therapy for VKC.
 Maintenance of an air-conditioned environment and control of dust
particles at home and work may also be beneficial. Local measures, such as
cold compresses and periodic instillation of artificial tears, have also been
shown to provide temporary relief.
Prof Ariyanto Harsono MD PhD SpA(K) 21

22. Prognosis
Since allergic conjunctivitis generally clears up
readily, the prognosis is favorable.
Complications are very rare, with corneal
ulcers or keratoconus occurring rarely.
Although allergic conjunctivitis may commonly
reoccur, it rarely causes any visual loss.
Prof Ariyanto Harsono MD PhD SpA(K) 22

23. References
1. Ventocilla M,; Chief Editor: Roy H. http://emedicine.medscape.com/article/1191467-
medication#5. Accessed 28 Nov 2014.
2. Vernal conjunctivitis. http://www.nlm.nih.gov/medlineplus/ency/article/001390.htm.
Accessed 28 Nov 2014.
3. Vernal conjunctivitis. http://en.wikipedia.org/wiki/Vernal_keratoconjunctivitis.
Accessed 28 Nov 2014.
4. Stock EL. Vernal Keratoconjunctivitis. In: Tasman W, Jaeger EA, eds. Duane's Clinical
Ophthalmology. 2013 ed. Philadelphia, PA: Lippincott, Williams & Wilkins: 2013:vol 4,
chap 9.
5. Rubenstein JB, Virasch V. Allergic conjunctivitis. In: Yanoff M, Duker JS, eds.
Ophthalmology. 3rd ed. St. Louis, MO: Mosby Elsevier; 2008:chap 4.7.
6. Barney NP, Graziano FM, Cook EB, Stahl JL. Allergic and immunologic diseases of the
eye. In: Adkinson NF, Jr., ed. Middleton's Allergy: Principles and Practice. 7th ed.
Philadelphia, PA: Mosby Elsevier; 2008:chap 64.
7. Hernandez-Trujillo V, Mitchell G, Lieberman P. Allergy. In: Rakel RE, ed. Textbook of
Family Medicine. 8th ed. Philadelphia, PA: Saunders Elsevier; 2011:chap 20.
Prof Ariyanto Harsono MD PhD SpA(K) 23