Introduction
The allergic reactions of conjunctiv a may assume several forms like (1) Seasonal allergic hay fever conjunctivitis (2) Perennial allergic conjunctivitis (3) Vernal keatoconjunctivitis (4) Atopic conjunctivitis (5) Giant papillary conjunctivitis (6) Contact dermato-keratoconjunctivitis and (7) Phlyctenular keratoconjunctivitis.1,2
Vernal keratoconjuncti vitis is a recurrent bilateral all ergicdisease of conjunctiva and cornea that is IgE mediated.2 It is also called as spring catarrh. The word vernal stands for the Greek word meaning ” occurring in spring ”.2,3 It is a misnomer because it is present throughout the year and more common in summer months.1,2,3 Duke Elder also suggested the occurrence is more common in summer months rather than spring season.3 This condition is more common in warm and dry climatic conditions. VKC is more common in boys until puberty thereafter the occurrence is equal in both the genders.[3,4] Some young adults develop more severe manifestation of the disease, sometimes with indefinite recurrences.4 About 2/3 of the patients have some form of allergic history and they are more commonly associated with childhood asthma and atopic conditions.4 The onset is usually after 5 years of age and it subsides usually after 25 years of age 5.2,3,4
There are three forms of this disease.
The palpebral form shows flat, red, raised polygonal papillae like a cobblestone appearance with bluish white colour. They are hard and made up of dense fibrous tissue with thickened conjunctival epithelium. The limbal form shows opacification, no dules and gelatinous thickening (cupid bow appearance) of the limbus. Characteristic white coloured Horner Tranta’s spots made up of eosinophilic and epithelial debris can also be seen at limbus.2,3,4,7 The disease can have a mixed form complicated by appearance of superficial punctate keratitis. The prognosis of the disease is usually good with some individuals developing recurrent disease. The complications/sequel include dry eyes, corneal ulcers (shield ulcers). Thickening and discoloration of the conjunctiva may persist sometimes.7,8,9,10
The diagnosis of vernal ke ratoconjunctivitis is usually based upon clinical signs and symptoms mostly but it can be aided by investigations like conjunctival scrapings and presence of eosinophilic infiltrates in it.7 Various therapeutic managements are suggested but most of them are for symptomatic relief, the curative therapies are often inadequate.8,11,12
We undertook this study to understand and stress upon the importance of clinical manifestations, to understand geographical variations of the disease and to know about the sequel of the disease and those of long-term me dications related complications.
Materials and Methods
This is a hospital based prospective cohort descriptive study conducted upon the patients visiting outpatient department of a tertiary care hospital at Surendranagar district, Gujarat. Proper ethical approvals were granted from the institutional ethics committee (human research) before commencing this study. A total of 134 patients were identified during the period of 12 months among of them 22 patients were lost on follow up. A total 112 patients were followed up. The relevant history and clinical examination data were noted on a specially designed proforma. The diagnosis was based upon history, clinical signs and symptoms and slit lamp examination. The chief complains were itching, ropy mucoid discharge, photophobia and foreign body sensation. Active disease was defined as presence of papillae, cobblestone appearance of palpebral conjunctiva, limbal gelatinization and corneal involvement. Quiescent form was defined as absence of current ocular symptomatology at present.2,3,4,7 Three forms of the diseases were identified and noted as (A) Bulbar (B) Palpebral (C) Mixed.9,7,8 The severity of the disease was noted as:
Complete ocular examinations including visual acuity, subjective correction, slit lamp examination, examination of conjunctiva especially for the signs of VKC like papillae, Horner Trantas spots at limbus with thickening of the conjunctiva and gelatinization of the limbus were done. Cornea was examined for epitheliopathies and shield ulcers. Staining and scraping of corneas were taken where required. Complete cycloplegic refraction was carried out where required. The patients were prescribed medications depending upon the severity of the disease and were followed up at one week interval for a month.
The inclusion criteria were all the patients attending outpatient department with signs and symptoms of vernal keratoconjunctivitis and consenting to the study. Those who do not consent were excluded from the study.
Results
This study was carried out at a tertiary care hospital catering mostly rural population in Gujarat state. Total 112 patients were identified and examined among them 94(83%) were male and 18 (16%) were female. The male to female ratio was 5:1. The patients were divided into three categories based upon age. In the first category, age group 5-10 years there were 83 (75%) patients, the second age group was 11-19 years which had 18 (16%) patients while the third age group containing patients older than 20 years of age had 11 (9%) of patients. Among these patients, 83 patients (75%) were from rural areas while 29 patients (25%) were from urban areas. Majority of the patients (47%) were presenting from lower socio-economical class, 36% from middle socio-economical class and 17% were belonging to upper socio-economical class. 65 patients (58%) were having the disease presentation for the first time and 47 patients (42 %) were having a history of previous occurrence of the same disease.
On clinical examination almost all patients (100%) were having papillae on palpebral conjunctiva. Macropapille were present in 3 0 % of population. 46 patients (4 1%) had cobblestone appearance. Horner Tranta’s spots were present in 10% patients. Limbal gelatinization was observed in more than half (>50%) of patients. The spring and summer season in total encountered for 31% of the cases compared to the rest of the year (69%). The mixed form was t he most common encounter (72%), followed by palpebral form (16%). The frequency of bulbar form was 11%. Symptoms like itching and ropy discharge was present in 93% and 88 % patients respectively. 34% patients complained about foreign body sensation and 25% patients had photophobia. The occurrence of VKC related complications were asTable 1 .
Majority of the patients had mild disease (63 patients; 56 %) while 32 patients (28%) had severe disease. Associated allergic conditions like eczema (14%), rhinitis (17%), childhood history of asthma (32%) and family history of atopy (35 %) were observed. The most common complication/sequel was corneal scarring (20%). It was followed by corneal neovascularization (17 %). Chronic medication related steroid induced pressure elevation was observed in less than 5% patients.
Age group distribution in vernal keratoconjunctivitis
Clinical form distribution
Table 1
| Associated Complication | Percentage of patients |
| Corneal Scar | 20% |
| Conjunctivization of cornea | 17% |
| Shield Ulcers | 10% |
| Cataract | 3% |
| Glaucoma | 5% |
| Acquired Ptosis | 2% |
| Keratitis | <1% |
Complications in vernal keratoconjunctivitis
Table 2
| Type of disease | Number of patients |
| Mild | 63(56%) |
| Moderate | 17(16%) |
| Severe | 32(28%) |
| Total | 112 |
Severity of vernal keratoconjunctivitis
Table 3
| Associated systemic condition | Percentage of patients |
| Asthma | 28% |
| Rhinitis | 15% |
| Eczema | 16% |
Associated Systemic conditions in vernal keratoconjunctivitis
Discussion
112 patients were enrolled from outpatient department having clinical signs and symptoms of vernal keratoconjunctivitis. Vernal keratoconuunctivitis is believed to be a childhood disease which is more common in pre-pubertal males and is found to resolve spontaneously at puberty. It is less common below the age of 5 years.3,4 This study show s that the prevalence pattern in tropical areas like Gujarat resembles most of the described Indian subcontinent pattern.
94 patients were male (83%) and 18 patients were female (17%). The youngest patient was of 5 years of age while the oldest patient was of 23 years of age. 9% of patients were above 20 years of age. The male: female ratio was observed to be 5:1. A hospital based study in south India by Saboo et al8 found the prevalence in males to be 87 % and the prevalence beyond the age of 20 was 12%, while the male: female ratio was observed to be 6.4:1. An international study by Lambiase and co-workers6 found the male: female ratio to be 3.5:1, while another study by Bonini et al 13,14,15 measured the male to female ratio as 4:1. An Nigerian study by Ukponmwan and co-workers16 found the male: female ratio as 1:1.3 whereas Leonardi et al17 from Italy described it as 3.3:1
An Indian clinical study in Hubli by Jivangi et al 18 and Saboo et al8 at South India found to have a mixed disease pattern to be more common (60% and 72% respectively). Whereas a neighbourhood study from Pakistan by Shaikh et al19 found the palpebral pattern as the most common finding (54%). While an inte rnational study series by Bonini et al13,14 found out the mixed type to be the most common (48%). This in relation to our study where the mixed pattern is among the most common occurrence (72%), followed by palpebral form and lastly the bulbar form.
Most of the patients were from lower socio economical class (53 %), whereas (17%) patients were from higher socioeconomical class, this is in contrast to Saboo et al8 which had higher incidence in higher socioeconomical class (67%).
Most of the patients presented in the summer months, presenting a chronic perennial form (75%), this is in contrast to the classical name vernal “occurring in spring”. This is in collaboration with the findings suggested by Saboo et al8 from south India and Sofi et al10 at Kashmir where perennial keratoconjunctivitis is more common (36% and 75% respectively). International studies by Lambiase et al6,13 suggested the incidence to be higher in summer months rather than spring season (60%).
Majority of the chief clinical presentations were papillae on tarsal conjunctiva (100%), photophobia (25%) and foreign body sensation (34%). Whereas a major Indian clinical study by Saboo et al8 measured the incidence of papillae (86%), photophobia (29%) and foreign body sensation (45%).
Family history of asthma was present in 28% patients, whereas family history of rhinitis and eczema was present in 15% and 14 % patients respectively. A study by Shaikh et al9 from Pakistan had the same outcomes (Family history of asthma 24% patients, history of rhinitis 25%), this is in contrast with a study by Saboo et al8 which showed 5% incidence of family history of allergic diseases which might be due to high temperate zone of our region.
Significant complications due to disease were corneal scarring (20%) and conjunctivization of cornea (17%) that is in line with the data reported by Saboo et al8 and Shaikh et al.9
Treatment related complication like cataract and steroid induced glaucoma was seen in 3% and 5% patients respectively. Saboo et al[8]20 reported the incidence of cataract an d steroid induced glaucoma to be 6 % & 3 % patients respectively.
In summary, typical clinical features of vernal keratoconjunctivitis were observed in this study like typical pre pubertal incidence and relevance after puberty with typical male to female ratio. The disease is self-limiting after puberty. Mixed pattern was the most common occurrence and patients with history of allergy/atopy are more prone to develop vernal keratoconjunctivitis.
