Vernal Keratoconjunctivitis (VKC)

• It is a chronic , bilateral conjunctival

inflammatory condition found in individuals
predisposed by their atopic background. It
is recurrent, interstitial inflammation of the
conjunctiva of periodic seasonal
incidence, self limiting disease/ condition
usually due to exogenous allergens.
• Characterized by flat topped papillae
usually on the tarsal conjunctiva
resembling cobble stones in appearance ,
a gelatenous hypertrophy of the limbal
conjunctiva, either discrete or confluent,
and a distinctive type of keratitis ,
associated with itching , redness of the
eyes lacrimation and mucinous or
lardaceous discharge usually containing
eosinophils
 Epidemiology
• Sporadically occurring with a wide
geographical incidence. Its more common
in India and the tropics than in U.K.
Colored races are particularly prone to
limbal form of disease.
• It is essentially a disease of youth
occurring most frequently between ages of
6 and 20 years.
• Sex incidence – Very high percentage of
cases are seen in males.
• Family History of allergy is found in 40 –
60 % cases.
 Etiology
• Three theories
1. Due to action of physical factors (as
heat, humidity and light)
2. Disorder of the endocrine glands
associated with vagotonic state
3. manifestation of an allergic condition.
Most affected people show a marked
hypersensitivity to a variety of antigens
(pollen, animal inhalants, ingestants etc)
 Symptoms
• Severe itching, photophobia, foreign body
sensation, ptosis, thick mucous discharge,
blepharospasm, burning, and typical
stringy discharge .
• Discharge is scanty, thick, ropy and
lardaceous, dirty white or cream colored.
 Signs
• The signs are confined to conjunctiva and
cornea; the skin of the lids are not
involved.
• Types
– Palpabral form
– Limbal/ Bulbar form
– Mixed type
Palpabral VKC

Conjunctiva develops a papillary response

in the upper tarsal conjunctiva.
Conjunctiva is congested later on
becomes milky.
Tarsal papillae are discrete larger than 1
mm in diameter, flat tops , they are
cobblestone in appearance.
 Limbal / Bulbar Form
• In limbal or bulbar form the first change is
usually a thickening, broadening and
opacification of the limbus which overrides
the corneal periphery as a semi-
translucent hood. This develop mostly at
the upper margin of the cornea
• Limbal papillae tend to be gelatinous and
confluent
• Limbal Nodules – Their most common site
is in the palpabral aperture, nasally and
temporally. In the raised mass, whitish
Horner- Trantas’s spots may occur at any
stage. Horner Trantas dots are collection
of epithelial cells and eosinophils.
• These changes may lead to superficial
corneal vascularization.
 Corneal Findings
• Punctate Epithelial Keratitis
• Horizontally oval ulcer in upper part of
cornea called Shield Ulcer
• Peripheral superficial gray white
deposition termed Pseudogeronton.
 Pathogenesis
• Biopsy of tarsal papilla in VKC reveals that
epithelium contain large number of mast cells
and eosinophils. Substantia properia contains
elevated number of mast cells, also contains
CD4 + T cells. Mast cells contains basic
fibroblast growth factor
• Cytology shows more eosinophils and
neutrophils, IgE and IgG have been isolated
from tears. Histamins and trytase are elevated in
tears
• Protein deposition diffusely in conjunctiva
• The flat-topped nodules are hard , and
consist chiefly of dense fibrous tissue , but
the epithelium over them is thickened ,
giving rise to the milky hue. Histologically
they are hypertrophied papillae, not
follicle. Eosinophils are present in them in
great numbers. In addition , infiltration with
lymphocytes, plasma cells , macrophages,
and basophils may also be seen.
 Diagnosis
• History
• Clinical findings (young boys living in
warm climates presenting with intense
photophobia, ptosis and gaint papillae)
 TREATMENT
1. Avoidance of allergen
2. Local Treatment
a. Steroids – Patients with significant seasonal
exacerbation , a short term high dose pulse
regimen of topical steroid is necessary.
Dexamethasone 0.1% or Prednisolon
Phosphate 1% , 8 times for one week brings
excellent result, tapered rapidly.
 b. Mast Cell stabilizer: Cromolyn
sodium, a mast cell stabilizer or a dual
acting drug such as Olopatidine, Ketotifen
or Azelastine (mast cell stabilization and
antihistamine)
c. Topical Cyclosporin-A (0.05%) twice
daily, it decreases the release of
interlukin-2, reduces expansion of T cell
clones.
Treatment of Corneal Shield Ulcer:
Antibiotic- steroid ointment and occlusion. If
plaque forms – superficial keratectomy

Phototherapeutic Keratectomy (PTK) and

Keratectomy with amniotic membrane
graft placement.
Surgical Treatment
Cryo-ablation of upper tarsal cobble
stones – but may lead to lid and tear film
abnormalities.

Injection of short term or long term acting

steroids into tarsal papilla has been shown
effective in reducing their size.
3. Systemic Treatment:
a. Non sedating antihistaminic
b. Oral Aspirin (high dose of 2400 mgm
daily)

4. Climatotherapy