EFFECTIVENESS OF STEROIDS VERSUS IMMUNOMODULATORS INTREATMENT OF VERNAL KERATO-CONJUNCTIVITIS. A STUDY AT ARMED FORCES INSTITUTE OF OPHTHALMOLOGY

Objective: To evaluate whether steroids or immunomodulator is a better mode of treatment in long term management of vernal keratoconjunctivitis.Study Design: A quasi experimental study. Place and Duration of Study: Armed Forces institute of Ophthalmology, Rawalpindi, from Feb 2019 to Oct 2019. Methodology: Ninety-two patients in between ages of 5-20 years were divided into two equal groups of 46 patients each. After instillation of 0.1% Fluoromethalone (steroid) into both eyes of patients of vernal keratoconjunctivitis, in group A and outcomes were compared with those of 0.05% Cyclosporine (immunomodulator) administered in the same manner in group B. All the patients were followed up regularly after 1, 3, and 6 weeks, 3 months, and 6 months and data recorded for inference. Results: Both the drugs were found to effectively reduce the foreign body sensation but had no or minimal effect on visual acuity and intraocular pressure (p-vale<0.001). Few patients in steroid group showed noticeable rise of intraocular pressure. (p=0.02). Cyclosporine was found to markedly reduce the mucoid discharge and photophobia without any adverse side effects (p-value=0.02). Conclusion: Cyclosporine appears to be more effective in control of mucous discharge and inflammation than steroids in vernal keratoconjunctivitis with minimal or no side effects and hence was found to be a safe alternative to steroid usage in long-term treatment groups.

Long Term Outcomes of Surgical Excision of Giant Papillae with Mitomycin C and Amniotic Membrane Transplantation in the Treatment of Refractory Palpebral Vernal Keratoconjunctivitis

Background and Objectives: To report the long-term outcomes of patients with refractory Vernal Keratoconjunctivitis (VKC) who underwent surgical excision of giant papillae (GP) with mitomycin C (MMC) 0.02% and amniotic membrane transplantation (AMT). Materials and Methods: This is a retrospective interventional single-center case series including five eyes of four patients who had refractory, symptomatic VKC with GP, along with corneal shield ulcers and/or punctate epithelial erosions. They underwent surgical excision of GP with MMC 0.02% alone (1 eye) or with MMC 0.02% and AMT (4 eyes). Their long-term visual and surgical outcomes were studied. Results: All subjects were male with bilateral involvement and mean age of presentation 9.8 years. The surgery was uneventful in all cases. Amongst the four eyes which underwent MMC with AMT, only one eye demonstrated papillary regrowth requiring repeat surgery. Postoperative follow-up ranged from 59 to 77 months (median 66 months). Four patients had the best corrected visual acuity (BCVA) >/= 6/9.5. One patient had BCVA 6/15 at the final follow-up due to the presence of anterior corneal stromal scar and poor ocular surface. Conclusions: Surgical excision of GP in combination with MMC and AMT, in refractory VKC, is a good treatment option with better clinical outcomes over a longer follow-up.

Treating Severe Pediatric Keratoconjunctivitis with Topical Cyclosporine A

The incidence of chronic keratoconjunctivitis, which potentially causes long-term loss of visual acuity due to corneal opacity, is considerably less common in children than in adults. It is therefore in danger of being overlooked. In children the appropriate treatment is therefore often introduced too late, or to an insufficient extent. In this article we would like to raise awareness about the diagnosis of chronic keratoconjunctivitis in children, and to present an effective treatment plan for severe stages of the disease. There are two forms of chronic keratoconjunctivitis that occur most frequently in children: hyperergic blepharokeratoconjunctivitis (hBKC) and vernal keratoconjunctivitis (VKC). With hBKC, the patient often has a history of recurring hordeolum and also presents with blepharitis; it is characterized by the marked presence of corneal neovascularization in the lower circumference of the cornea. VKC is typically characterized by changes under the upper eyelid, with marked changes to the superior limbus. If there is a risk of complications involving the cornea, or in the presence of such complications, a consistent long-term topical immunosuppressive and anti-inflammatory treatment is required. Both of these properties are combined in the active ingredient cyclosporine A. Other advantages of topical CSA treatment are its steroid-sparing effect and the long-term reduction of exacerbations. Parents need to be informed about the chronic nature of these two diseases and their tendency to recur; because of these characteristics, treatment, in most cases, should be envisaged for at least one year in order to effectively disrupt the complex immunologic processes. This safeguards the childʼs visual development and prevents amblyopia caused by scarring and astigmatism. We hope that the data presented will lower the barriers related to prescribing CSA for topical eye application in children.

COMPARATIVE STUDY OF THE EFFICACY OF TOPICAL LOTEPREDNOL ETABONATE AND FLUOROMETHOLONE IN THE TREATMENT OF VERNAL KERATOCONJUNCTIVITIS : A RANDOMISED CONTROLLED STUDY

Introduction:Vernal keratoconjunctivitis(VKC) is a chronic, recurrent, inammatory disease of ocular surface showing seasonal exacerbation, affecting young children. Topical steroids are the mainstay in the treatment of ocular allergy, but their use should be judicious since they carry serious side effects . Loteprednol and uorometholone carry better safety prole. Present study was conducted with the aim of comparing the efcacy of these two widely used steroids.Objectives:To compare total subjective symptom score (TSSS), total objective sign score (TOSS) and side effects of medications before and after treatment at each visit.Materials & Methods:A prospective randomised controlled study was performed on 92 patients of VKC over four weeks. Patients were allotted to either of the two arms of treatment (i.e. LP 0.5% or FML 0.1%). Subjective and objective assessments of the signs and symptoms of VKC were done using standard scoring methodologies at 7, 14, 21 and 28 days post treatment. The main outcome measure was measured in terms of TSSS and TOSS before and after treatment at each visit. Secondary outcomes included side effects. Statistical analysis of the data collected was carried out.Results: Loteprednol showed greater reduction in symptoms initially but by the end of study there was no statistically signicant difference in effect between the two drugs.Conclusions: Final improvement in clinical features and safety prole, at the end of 4 weeks was similar in eyes treated with either of the two drugs. Hence, both the drugs can be safely used in the treatment of VKC.

Efficacy of Supratarsal Triamcinolone Injection versus Dexamethasone in Recalcitrant Vernal Keratoconjunctivitis

Aim: To determine the effectiveness of supratarsal triamcinolone injection versus dexamethasone in recalcitrant vernal keratoconjunctivitis. Study Design: Prospective/randomized study Place and Duration of Study: Department of Ophthalmology, Lorallai Medical College, Loralai from 1st October 2020 to 31st March 2021. Methods: Fifty patients (100 eyes) of both genders and age between 12-40 years were enrolled. Detailed demographics of enrolled cases age, sex and body mass index were recorded after taking informed written consent. All patients had recalcitrant vernal keratoconjunctivitis. Patients were equally divided into 2-groups. Group I had 25 patients and received 20mg of supratarsal triamcinolone injection in both eyes and group II with 25 patients received 2mg of dexamethasone in their eyes. Postoperative effectiveness, complications and recurrence of disease was observed and compared among both groups. Results: There were 15 (60%) males and 10 (40%) females in group I with mean age 18.14±6.34 years while in group II, 15 (60%) males and 10 (40%) females with mean age was 17.68±4.54 years. Palprebral vernal keratoconjunctivitis was found in 36 eyes (10 patients of group I and 8 patients of group II) and Mixed vernal keratoconjunctivitis in 64 eyes (15 patients of group I and 17 patients of group II). Symptoms were itching,photophobia, lacrimation and pain. Conjunctival hyperemia, giant papillae and limbal infiltrate were the most common signs observed. Post operatively effectiveness among group I and II was (100% vs 92%) without any complication. Recurrence rate of vernal keratoconjunctivitis in group I was lower 4% as compared to group II 10%. Conclusion: The use of supratarsal triamcinolone injection in patients of recalcitrant vernal keratoconjunctivitis was effective and safest method as compared to dexamethasone in terms of less recurrence and high rate of efficacy. Keywords: Supratarsal triamcinolone, Dexamethasone, Vernal keratoconjunctivitis, Effectiveness, Recurrence