Spring conjunctivitis, also known as spring cicatricial conjunctivitis and seasonal conjunctivitis. It is a type of allergic conjunctivitis that is most common in the spring, hence the term “spring” conjunctivitis. The main symptoms in affected patients are itching, lacrimation, photophobia, and mucous discharge. The disease is “self-limiting”. It starts before puberty and is more severe between the ages of 3 and 10. It lasts for 5-10 years, mostly in both eyes, with a higher incidence in boys than in girls. Effective drugs include topical glucocorticoids and mast cell stabilizers.
The incidence is higher in the spring and summer than in the fall and winter. The typical features are giant papillae in the conjunctiva of the upper lids bilaterally, but sometimes also in the conjunctiva of the corneoscleral rim area. The predominant symptom is persistent itching that tends to worsen in the evening after various irritations during the day, such as dust, dandruff, bright light, wind, sweat stains, and rubbing. Other symptoms are pain, foreign body sensation, photophobia, burning sensation, tearing and mucous discharge.
Physical signs
1. Changes in the conjunctiva
The lid conjunctiva and bulbar conjunctiva are the main sites of involvement, with pavement-like papillary reactions in the upper lid conjunctiva, where the papillae sometimes fuse. These papillae in the lid conjunctiva are polygonal with a flattened head, clearly visible to the naked eye, and are visible under slit lamp with a diameter of 1-8 mm, connected to each other, each with a central vessel, fluorescein can stain the top of the papillae, and there is often a layer of mucous milky secretion between the papillae and their surface, forming a mucous pseudomembrane.
Corneoscleral rim changes mostly occur in people of color, mainly manifested as gum-like nodules or bulges in the corneoscleral rim area, mostly located in the upper 1/2 of the corneoscleral rim area, superfluous small white spots, called Horner-Trantas spots.
2. Corneal changes
In patients with VKC, the degree of corneal involvement can be used as an indication of disease severity, and corneal complications are present in patients with either eyelid-type or mixed VKC. Superficial epithelial keratitis is a common corneal manifestation, which is characterized by the presence of punctate dark gray cloudy, dust-like areas in the upper 1/2 of the cornea. These punctate areas can break down and fuse, forming larger erosions called spring spots and shield ulcers.
Patients with VKC can also develop stromal keratitis. The most common corneal degenerative change is the pseudogeriatric ring, an arcuate superficial stromal clouding located primarily in the periphery of the cornea that sometimes ulcerates. Pseudogeriatric rings are often accompanied by neovascularization into the peripheral part of the cornea, forming a vascular opacity over the cornea.
3. Changes in the external eye
Common signs include ptosis, which may be associated with increased eyelid weight secondary to spring papillary hypertrophy, and sometimes excessive folds of lower lid skin may be observed.
Complications
Associated diseases with VKC include cone corneas and atopic cataracts, and corneal ulcers, keratoconjunctivitis, spherical conjunctiva, and hyaline limbal degeneration are also common.
Treatment
1.General measures
The main thing is to change the environment of VKC patients. If necessary, an allergist should be involved in the development of a treatment plan. Immunodesensitization therapy is effective in patients who are severely sensitized to only a small and well-defined number of allergens.
Cold compresses and ice packs may provide temporary relief. Similarly, occlusive therapies, such as masking, goggles, and lid margin sutures, may provide temporary symptomatic relief.
2. Antihistamines
Systemic use of antihistamines is generally considered preferable to topical use. Patients are sometimes sensitized to the preservative components of topical medications. Commonly used drugs are: terfenadine and/or astemizole.
3. Glucocorticoids
Glucocorticoids remain the mainstay of VKC treatment, especially for very severe cases. Short-term topical therapies (boosting and tapering) are generally considered very useful to control the state of deterioration and interrupt the inflammatory cycle.
4. Mast cell stabilizers
are the main agents used in the treatment of VKC, and these agents greatly reduce the need for topical application of glucocorticoids. Sodium cromoglycate is used topically. However, sodium cromoglycate is not effective for the acute deterioration phase and often requires first topical glucocorticoids to control the inflammatory response. Thereafter, topical sodium cromoglycate can be used as a prophylactic maintenance drug.
5.Non-steroidal anti-inflammatory drugs
NSAIDs proven to be effective in ophthalmic diseases include the epoxygenase inhibitors sodium diclofenac, thiamphenicol, flurbiprofen and ketorolac. 0.5% ketorolac bradykinin eye drops are mainly used for the treatment of seasonal allergic conjunctivitis. Flurbiprofen and thiamphenicol are mainly used for intraoperative pupil narrowing. Diclofenac sodium is used to treat postoperative inflammatory reactions.
6.Adjunctive drugs
Mucolytic agents can be used topically to dilute or dissolve the mucous secretions of VKC. Use 1% to 2% sodium carbonate (monohydrate) and other acidic dilutions. Acetylcysteine 10% may also be used to control mucus formation.
Topical vasoconstrictors can temporarily reduce conjunctival edema and congestion to relieve symptoms. Other drug therapies include topical cyclosporine A and systemic aspirin, indomethacin, and tolmetin.
Corneal epithelial defects (peltate ulcers) are atrophic lesions. Effective treatment requires first topical glucocorticoids to temporarily control ocular inflammation.
7. Surgical treatment
Cryotherapy of the lid conjunctival surface can temporarily relieve the symptoms of VKC. Surgical removal of a large number of dystrophic papillae may also have the same effect. However, after performing either of these procedures, the papillae will rapidly recur and return to symptoms. Surgery may also result in some long-term complications such as scar formation, impingement, tear deficiency, and entropion.