Vernal and Atopic Keratoconjunctivitis

Key Concepts

Vernal and atopic keratoconjunctivitis are chronic, vision-threatening, allergic diseases of the eye.
Vernal keratoconjunctivitis occurs most commonly in young males, often with a seasonal pattern, but also with occasional perennial disease.
Atopic keratoconjunctivitis occurs in the second through fifth decade in patients with atopic dermatitis.
Mast cell activation is implicated in both diseases; however, inflammatory cell-mediated immunopathologic changes likely drive the development of vision loss.
Conjunctiva and cornea scar formation are the main reasons for decreased visual acuity in these disorders.

Atopy refers to hypersensitivities in persons with a hereditary background of allergic diseases, as first described by Cocoa and Cooke. The major and most commonly recognized atopic conditions include eczema (atopic dermatitis), asthma, hay fever, and allergic rhinitis. Atopic conditions affect 28%–32% of the population. Atopic ocular diseases include seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), and giant papillary conjunctivitis (GPC). VKC and AKC may cause significant complications and lead to loss of vision. Type I hypersensitivity reactions of the ocular surface are important in AKC and VKC but are not considered the only pathophysiologic mechanism in these similar yet distinct entities. VKC and AKC are discussed separately and compared and contrasted.

Vernal Keratoconjunctivitis

Definition

VKC is a chronic, bilateral conjunctival inflammatory condition found in individuals predisposed by their atopic background. An excellent review of the history and description of this disease was published by Kumar in 2008. Beigelman’s 1950 monograph Vernal Conjunctivitis continues to be the most exhaustive compilation on this disease and is unmatched in current times.

Demographics

The onset of disease is generally before age 10 and lasts 2–10 years, usually resolving during late puberty. Only 11% of patients were older than 20 years of age in the Bonini series. Males predominate in the younger ages, but the male to female ratio is nearly equal in older age patients. Young males in dry, hot climates are primarily affected. The Mediterranean and West Africa are areas with the greatest prevalence. Less than 10% of all patients in a single series had onset of typical signs and symptoms of VKC as adults. VKC is relatively unusual in most of North America and Western Europe. There is a significant history of other atopic manifestations, such as eczema or asthma, in 40%–75% of patients with VKC. A family history of atopy is found in 40%–60% of patients. Seasonal exacerbation, as the name implies, is common, but patients may have symptoms year-round.

Symptoms

Severe itching, redness, tearing, and photophobia are the main symptoms of VKC. Associated foreign body sensation, ptosis, thick mucous discharge, and blepharospasm occur.

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