Treatment of vernal keratoconjunctivitis in patients with an intact cornea

AKC: atopic keratoconjunctivitis; IgE: immunoglobulin E; 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 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 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.

◊ Patients who are asymptomatic on only a dual-acting agent or mast cell stabilizer for a season can do a trial without therapy the following season to determine if the disease has resolved.

§ Second- and third-generation oral antihistamines include fexofenadine, loratadine, desloratadine, cetirizine, and levocetirizine.

¥ Ophthalmic topical corticosteroids can cause sight-threatening complications such as cataracts and increased intraocular pressure leading to glaucoma. Thus, these medications should be prescribed and the patient monitored by an ophthalmology specialist, and the dose and duration of therapy should be minimized. Refer to UpToDate topic on VKC for use of topical corticosteroids for VKC.

‡ 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 AKC and severe perennial atopic conjunctivitis.