We often encounter a special type of conjunctivitis in children with oddly itchy eyes every spring and summer. It is very difficult to treat because of the redness of the eyes during attacks and the amount of discharge, which can affect vision in severe cases, and although there are many medications for this type of disease, most physicians give few recommendations for long-term standardized treatment. In order to prevent complications and alleviate the suffering of children with the disease, a detailed introduction to the standardized drug regimen from questions and answers is hereby made!
1. What is spring cicatricial keratoconjunctivitis?
Spring Catarrhal Conjunctivitis is a seasonal, immunologic disease. VKC usually strikes before the age of 10 years and is delayed for 2 to 10 years, often resolving in late adolescence. Between 40% and 75% of patients with VKC have a typical history of other atopic manifestations, such as eczema or asthma, and between 40% and 60% have a family history of atopic disease.
2. What are the etiology, symptoms and staging of keratoconjunctivitis in spring?
The etiology may be the result of a combination of type I and type IV hypersensitivity reactions. Allergens may be pollen, microorganisms, animal feathers, dust, etc. Itching and photophobia are the main symptoms. It may also be accompanied by foreign body sensation, tearing, ptosis, mucus discharge and blepharospasm.
It is divided into three types.
(1) Lid conjunctival type The lid conjunctiva and bulbar conjunctiva are the main sites of involvement, mostly the upper lid conjunctiva is involved, the lower lid conjunctiva is normal or slightly diseased, and the fornix conjunctiva is not invaded. The papillae of the lid conjunctiva are mostly discontinuous, larger than 1 mm in diameter, flattened apically, and stain positively for fluorescein, with a typical “pavement-like papillae”. Between the papillae and on their surface, there is often a layer of mucousy milky white secretion, forming a mucous pseudomembrane.
(2) Corneal rim type is common in Asians and Africans. It appears as a colloid-like nodule or bulge at the corneal margin, mostly located in the upper 1/2 of the corneal margin area. These changes can lead to neovascularization of the corneal limbus, and the curved conjunctiva usually does not become superficial or cause lid adhesions.
(3) Mixed type Both of these manifestations are present simultaneously.
3. How is spring keratoconjunctivitis diagnosed?
Seasonal episodes, commonly seen in children and adolescents, with persistent pruritus, pavement-like papillae on the upper lid conjunctiva or gum-like elevation of the corneal rim, and microscopic conjunctival scrapings showing more than 2 eosinophils per high-powered field of view, make the diagnosis of the disease relatively straightforward when combined with the history and examination findings.
However, some patients can present with atypical signs and symptoms, for example, some patients may have perennial attacks, and some patients with the corneal rim type do not yet have the typical corneal rim colloid bulge. In severe cases, a shield ulcer, as it is called, usually occurs only in younger patients and is often located above the cornea in a transverse oval shape, with the ulcer area often inhibiting normal re-epithelialization. The ulcerated area is very slow to heal and often results in a gray, oval-shaped subepithelial clouding.
4.Commonly used medications for spring keratoconjunctivitis?
(1) Routine management: As with any atopic disease, it is important to avoid exposure to allergens. Local cold compresses may reduce symptoms. Relocation to colder areas is possible if available.
(2) Antihistamines Antagonize the biological activity of already released inflammatory mediators and reduce symptoms, often in combination with mast cell stabilizers. For example, 0.05% emetine fumarate (Emetine), Nassauda.
(3) Mast cell stabilizers work by inhibiting cell membrane calcium channels. For example, 0.1% lodosamide (Alamax), 2%-4% sodium cromoglycate, 2% nedolomide. It is best used before exposure to allergens, is poorly effective in treating patients who have already had an attack, and is ineffective in the acute exacerbation phase. Currently, they are mostly used to prevent attacks or for maintenance treatment.
(4) Dual-acting drugs such as olopatadine (Patanol), azelastine, ketotifen.
(5) Glucocorticoids are the main drugs used to treat severe VKC. Short-term, high-dose topical hormone shock therapy is the key to mitigate long-term hormone side effects, with regimens such as 4x/day,2 days; 3x/day,2 days; 2x/day,2 days; 1x/day,3 days, followed by discontinuation. As with all chronic inflammatory diseases of the eye, there is a risk of cataract and glaucoma with long-term glucocorticoid use. Therefore, low-dose maintenance therapy is generally not recommended. Safer hormonal eye drops such as Lutasol and Flomax, which have a small effect on IOP elevation, can be used.
(6) Immunosuppressive agents can be applied locally in recalcitrant cases. CsA can reduce the release of inflammatory cytokines, thereby reducing the expansion of certain T-cell clones. Tacrolimus (FK506) inhibits the release of histamine and other allergic mediators from mast cells and reduces the production of cytokines.
(7) Artificial tears dilute the inflammatory matrix and flush the role of allergens and inflammatory mediators, long-term use is recommended to use artificial tired ah without preservatives.
5, the standardized recommended treatment plan.
(1) basic treatment: choose an antihistamine drops and a mast cell stabilizer, also available to combine these two eye drops of dual-action drugs, such as Patanlo. Plus a preservative-free artificial tear solution.
(2) When the symptoms are severe and the above drugs are not well controlled, short-term use of hormonal eye drops that have a smaller effect on IOP levels can be chosen for a course of 4 times/day for 2 days; 3 times/day for 2 days; 2 times/day for 2 days; 1 time/day for 3 days, and then discontinued. Generally, only one course of hormonal eye drops can be used in January to reduce the occurrence of other hormonal complications such as glaucoma and cataract.
(3) In order to reduce the complications of hormones, tacrolimus (FK506) (powerful, higher price) and cyclophilin A (CsA) eye drops (weaker, lower price) can also be used.
6. Can Quikata keratoconjunctivitis be treated surgically?
Historically, surgical treatment has occupied the most important position. Cryoablation has been reported to be effective for short-term improvement of upper lid pavement-like hyperplasia symptoms. However, the resulting scarring can lead to eyelid and tear film abnormalities. Because of these permanent side effect risks, this treatment is not approved for this usually self-limiting condition. Surgical excision of the upper lid papilla combined with anterior displacement of the conjunctival curvature or oral mucosal graft may result in the disappearance of the curvature. Sublid papillary injections of short- or long-acting steroid hormones have been shown to be effective in reducing papillary size.
Recent multicenter clinical trials have shown that tacrolimus (FK506) ophthalmic solution significantly improves giant papillae with pavement-like enlargement of the upper lid.