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Keratoconjunctivitis diagnostic and therapeutic challenge in paediatric population

Different treatment approaches required for vernal, atopic forms 
of disease in children

Sean Henahan

Posted: Tuesday, November 1, 2016

bremond-gignac-vkc-image

Slit lamp examination: tarsal form of vernal keratoconjunctivitis. Courtesy of Dominique Bremond-Gignac MD, PhD

Atopic allergic keratoconjunctivitis is a diagnostic and therapeutic challenge in the paediatric population. Because of potentially vision-threatening complications, it is essential to know how to recognise and treat this rare disease, says paediatric ophthalmologist Dominique Bremond-Gignac MD PhD.
“Usually we think of atopic allergic conjunctivitis as a disease of adults. When we have severe ocular allergy in children we tend to think it is vernal keratoconjunctivitis. But we know that in fact we do have younger patients with atopic disease and allergic conjunctivitis, and although it is rare, we need to be looking for it,” said Dr Bremond-Gignac, of Neckar University Children’s Hospital, Paris, France, who was speaking at the 2016 WSPOS Subspecialty Day in Copenhagen, Denmark.
She noticed in her paediatric clinic that some patients with apparent vernal conjunctivitis also had ongoing atopic dermatitis. When she sees children with severe ocular allergic disease who also have atopic dermatitis, she now diagnoses this as atopic vernal keratoconjunctivitis.
“It is important to make this distinction because the prognosis is different. Vernal keratoconjunctivitis stops in adulthood, while atopic vernal keratoconjunctivitis is a lifelong disease. It is Important to understand that this is a specific pathology of childhood,” she said.

FAMILY HISTORY
Dr Bremond-Gignac recently published a survey article about 23 such patients (Ophthalmology, Vol. 123, Issue 2). Mean ages at onset of symptoms and at initial presentation to an ophthalmologist were 5.2 and 8.1 years, respectively. All of the patients suffered from eczema and conjunctivitis/keratitis. Most also had a family history of atopic disease and were affected by asthma and allergic rhinitis.
The most common presenting symptoms included eczema, conjunctival hyperaemia, and keratitis, the latter including superficial punctate keratitis, shield ulcer and corneal erosions. Other symptoms included blepharitis, facial cutaneous fissures, papillae and madarosis.
These patients are treated by a team of specialists which can include a paediatric ophthalmologist, a paediatric dermatologist, an allergist and an immunologist.
Treatment starts with ocular washing, which can help to remove the allergen and the inflammatory elements. The first level of treatment includes antihistamines and mast cell stabilisers in drop form, preferably without preservatives.
“Depending on the severity of the disease, we may need to choose more intensive treatment. When standard antihistamines don’t suffice, we consider going to topical corticosteroids, but we know steroids have complications, so we would never use these long-term. We prefer a steroid-sparing approach,” said Dr Bremond-Gignac.
She reported good results when using the topical calcineurin inhibitor cyclosporine as the next line of treatment. This is commercially available in the USA as a 0.05% drop (Restasis, Allergan), but is not available as such in Europe.
She noted that she does expect this agent to be available commercially in Europe soon, with indication for vernal keratoconjunctivitis, and possibly at some point for allergic keratoconjunctivitis as well.
Her clinic laboratory currently formulates cyclosporine in concentrations ranging from 0.05 to 2.0%. Patients receive drops in various strengths, one to four times per day, depending on the severity of the disease.
“We tend to treat with the season, but depending on the allergen, the season could be a very long period,” she told EuroTimes.
She emphasised that there are important differences in the treatment of atopic keratoconjunctivitis and vernal keratoconjunctivitis. Patients with atopic disease will likely need treatment for 
the dermatologic aspects of the disease with emollients, demulcents and 
possibly corticosteroids.
“These differences in the optimal treatment of atopic and vernal keratoconjunctivitis highlight the importance of early and accurate diagnosis, in informing effective treatment strategies and improving patient outcomes,” she said.
Dominique Bremond-Gignac:
dominique.bremond@aphp.fr