To the Editor:
Vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) are severe allergic diseases of the ocular surface that can have sight-threatening complications such as corneal macro-erosion, shield-shaped ulcers and plaques [1, 2] (Fig.1). They are underdiagnosed and undertreated due to the similarity of symptoms to non-sight-threatening ocular allergies, and the lack of a consistent management approach [3]. Specifically, practitioners may be unaware of the benefit of a short pulse of oral corticosteroids (OCS). In this article we review clinical practice at a UK tertiary referral centre and propose a management algorithm.
The study was registered as a service evaluation. We reviewed the medical records of Fifteen children prescribed OCS (prednisolone 1 mg/kg for three days) for VKC/AKC between 2008 and 2018, noting age, gender, severity of corneal epithelial disease (modified Cameron [1]), and outcome including the proportion of ulcers healed within 2 weeks of starting OCS, proportion requiring surgical intervention, and time between starting OCS and re-epithelialisation. In children prescribed OCS on multiple occasions, these were included as distinct episodes, resulting in 30 interventions.
The median age at diagnosis was 11 years (IQR 9–14). All but one patient were boys (94%). Indications for OCS were as follows: the presence of ulceration or severe punctate corneal epitheliopathy indicative of imminent ulceration; to control inflammation before and after lamellar keratectomy. Twelve interventions (40%) involved grade 3 lesions (Fig.1). Of these, OCS was supplementary to superficial keratectomy in 7 (58%), with early re-epithelialisation in all cases. In the five who did not have early keratectomy, two resolved with OCS alone but two eventually required keratectomies (48 and 63 days after starting OCS). One was lost to follow-up. Four cases (13%) involved grade 2 lesions. Two re-epithelialised within 14 and 28 days but two required superficial keratectomy four weeks after starting OCS. Ten interventions (33%) involved stage 1 lesions, of which six re-epithelialised within 14 days, one within 22 days, and three were lost to follow-up. Four cases (13%) received OCS for pre-stage-1 lesions, with the epithelium stabilising within 14 days. No child suffered adverse events from OCS.
In summary, OCS led to swift re-epithelialisation across severity gradings 1–3 when used as an adjunct to lamellar keratectomy or as the primary treatment. The limitations of this study are its retrospective design and lack of controls. We sought to reduce selection and reporting bias by including all children treated with OCS for severe allergic eye disease during the observation period. A recent review of ocular allergy treatment includes OCS for recalcitrant VKC [4], but few studies have reported the use of OCS in VKC. In a case of paediatric AKC resistant to topical treatment there was a good response to oral immunosuppression including OCS [5]. Clinical experience suggests that OCS is likely a safe and effective treatment or adjunct to surgery for severe VKC/AKC. Ideally, a RCT could formally test this. However, the rarity of this condition and the lack of a suitable placebo hampers study design. In the interim, we recommend the treatment algorithm illustrated in Fig. 2, with regular audit of outcomes.
References
Cameron JA. Shield ulcers and plaques of the cornea in vernal keratoconjunctivitis. Ophthalmology. 1995;102:985–93.
Reddy JC, Basu S, Saboo US, Murthy SI, Vaddavalli PK, Sangwan VS. Management, clinical outcomes, and complications of shield ulcers in vernal keratoconjunctivitis. Am J Ophthalmol. 2013;155:550–9.e1.
Bonini S, Sacchetti M, Mantelli F, Lambiase A. Clinical grading of vernal keratoconjunctivitis. Curr Opin Allergy Clin Immunol 2007;7:436–41.
Leonardi A, Silva D, Formigo DP, Bozkurt B, Sharma V, Allegri P, et al. Management of ocular allergy. Allergy. 2019;74:1611–30.
Li J, Luo X, Ke H, Liang L. Recalcitrant atopic keratoconjunctivitis in children: a case report and literature review. Pediatrics. 2018;141:S470–4.
Funding
This work did not receive funding. It was supported by the NIHR Moorfields Biomedical Research Centre
Author information
Authors and Affiliations
Contributions
PF and MC analysed the data and wrote the manuscript. EM carried out the search of electronic patient records to identify cases. ADN designed the audit and reviewed all stages of the work. MH, DFPL and ST reviewed the audit design, data and manuscript.
Corresponding author
Ethics declarations
Conflict of interest
ADN is advisor to Santen Inc.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Fernando, P., Marziali, E., Chlubek, M. et al. Pulsed oral corticosteroids for the treatment of vernal and atopic keratoconjunctivitis: a management plan. Eye 35, 1277–1278 (2021). https://doi.org/10.1038/s41433-020-1062-2
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/s41433-020-1062-2