Treatment of vernal keratoconjunctivitis

VKC: vernal keratoconjunctivitis.
* Topical dual-acting mast cell stabilizers/antihistamines include olopatadine, azelastine hydrochloride, epinastine, pemirolast potassium, and ketotifen fumarate.
¶ Basic eye care and trigger avoidance include the following:

• Avoidance of nonspecific triggers, such as wind, heat, salt water, and sunlight whenever possible.
• Avoidance of known allergens in patients with immunoglobulin E (IgE)-mediated disease (this can be challenging as patients with VKC can react to multiple allergens).
• Avoidance of eye rubbing as it leads to a mechanical mast-cell degranulation, as well as exacerbation of the allergic process.
• Artificial tears, especially in patients who develop tear film insufficiency due to the anticholinergic effect of systemic antihistamines.
• Cool compresses.

Δ Second- and third-generation oral antihistamines include fexofenadine, loratadine, desloratadine, cetirizine, and levocetirizine.
◊ Symptoms most commonly occur during the spring pollen season but can extend into other seasons, depending upon allergen levels, and may occur nearly year round.
§ Topical ophthalmic corticosteroids include prednisone acetate 1% and dexamethasone 0.1% for severe cases and prednisolone acetate 0.12%, fluorometholone, medrysone, loteprednol, etabonate 0.2 or 0.5%, and rimexolone 1%. Side effects of ophthalmic corticosteroids include cataracts and increased intraocular pressure leading to glaucoma. Thus, dose and duration of therapy should be minimized.
¥ A topical ophthalmic calcineurin inhibitor (eg, cyclosporine 2% or tacrolimus) is used instead of a topical corticosteroid if the corneal epithelium is compromised. Additional therapy is used for corneal shield ulcers.
‡ The patient is started on allergen immunotherapy if pollens are positive on testing and there are no contraindications. VKC is unlikely if aeroallergen testing to pollens is negative, and the patient should be evaluated for alternative diagnoses including atopic keratoconjunctivitis (AKC) and severe perennial atopic conjunctivitis.
† Systemic cyclosporine is limited to those with severe, sight-threatening disease, usually in patients with severe chronic allergic disease with seasonal exacerbation (VKC plus AKC or VKC plus severe perennial atopic conjunctivitis) who may require longer-term treatment.