P10\u2005Management of severe atopic and vernal keratoconjunctivitis

Abstract

Background Vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) are severe allergic diseases of the ocular surface which can have sight-threatening complications such as shield-shaped ulcers and plaques. Paediatricians, general practitioners and optometrists play an important role in the early detection of severe VKC and AKC to ensure swift onwards referral to an eye clinic for treatment with topical or oral immunosuppressants or modulators and, if required, surgical intervention. Purpose To evaluate the indications for oral corticosteroid treatment, as an indicator of severe inflammation requiring systemic immunosuppression, in the management of VKC/AKC in children, and to describe treatment outcomes. Methods We reviewed the medical records of children up to the age of 16 years who had been prescribed oral corticosteroids for VKC/AKC at a tertiary referral centre in the UK between 2008 and 2018. We noted age, gender, severity of corneal epithelial disease (Cameron and Moorfields grading systems), proportion of ulcers healed within 2 weeks of starting oral corticosteroids, proportion of children requiring surgical intervention, and time from starting steroids to epithelialisation. In children who received oral steroids on more than one occasion, we included the first episode only. Results We identified 16 children and young people (median age 11.5 years, interquartile range 9–14); 15 (94%) were boys. Seven (44%) children with severity grade 1 Cameron/2 Moorfields had received oral corticosteroids in addition to topical eye drops; re-epithelialisation in under 14 days was achieved in 86% (6/7), while 14% (1/7) required additional superficial keratectomy. Seven (44%) patients with severity grade 3 (established plaque) received oral steroids; in four it was supplementary to superficial keratectomy, given for anti-inflammatory purposes, and to prevent recurrence of the ulcer due to uncontrolled inflammation. In three, elective keratectomy was not carried out initially; one plaque ulcer resolved spontaneously, while two did not re-epithelialise and required surgery 48 and 63 days after oral steroids were started. Two (13%) patients with low-grade lesions received oral therapy due to imminent risk of progression. Re-epithelialisation time was measured for one of these patients and found to be under 14 days. Conclusions The clinical signs of severe VKC/AKC which require topical and/or systemic corticosteroids can be detected without specialist equipment, by instillation of fluorescein eye drops. Swift referral to an eye clinic allows timely treatment and optimises outcomes. We propose a simple algorithm to guide management.