Q: What’s the best approach for younger kids with severe flare-ups of vernal conjunctivitis that include corneal findings? Is it okay to use cyclosporine or tacrolimus? If employing a tiered approach, how do you use steroids?
A: While not the most common expression of allergic eye disease, vernal conjunctivitis is a distinct clinical entity that is seen occasionally with corneal findings. Seasonal in nature, this expression of severe allergic disease presents mostly in prepubescent males, ages six to 12. Some of these cases, although worse in the spring, can run through summer into fall, requiring longer-term therapy.
Flare-ups are chronic and recurrent, but typically subside once the patient has reached puberty.1 Symptoms include light sensitivity; blepharospasm; profound itching (which can be almost debilitating); and a vast amount of excess, stringy, ropy mucus. Also, the limbal and paralimbal tissues will have a milky, gelatinous appearance. Generally, it’s sectorial, but occasionally it involves the entire limbal circumference. Recalcitrant shield ulcers are also troubling and potentially sight-threatening when they occur.
Look through the patient’s chart and talk with them about the history so you can base your prescribing on this past experience. Some doctors have had success with cyclosporine, a low-potency immunomodulator, and tacrolimus, a non-steroidal immunosuppressant. Cyclosporine 0.05% (Restasis, Allergan) used b.i.d. or more often (or 0.03% tacrolimus ointment b.i.d.) can reduce the need for ongoing steroid usage or minimize the amount of steroid with any long-term therapy or refractory case.
Caution: If tacrolimus is used, monthly blood work with appropriate lab tests is needed. However, treatment of vernal conjunctivitis with either of these medications is an off-label ophthalmic use, which is why practitioners often shy away from using them.
Common presentation of limbal vernal conjunctivitis. Photo: Randall Thomas, O.D., M.P.H.
“What the patient must have early on is aggressive use of a steroid, and there’s likely to be a protracted use of the medication,” says Randall Thomas, O.D., M.P.H., who works with a group practice in Concord, N.C. “So you want to go with an ester-based corticosteroid, because it’s safe and highly clinically effective.” Two concentrations are available—loteprednol etabonate 0.2% (Alrex, Bausch + Lomb) or 0.5% (Lotemax, Bausch + Lomb).
Dr. Thomas usually prescribes the higher concentration, with dosing every two hours for three to four days to aggressively get the allergic reaction under control. “Once you’ve done that, it should calm the storm, and then you can start tapering the Lotemax down, usually over a one- to four-week period,” he says.
To make sure the symptoms have been eradicated, have the patient come into the office one to two weeks after treatment is initiated. Carefully monitor pressure because, even though loteprednol etabonate has a very safe clinical profile, it does have the potential to raise IOP––particularly in children. Dr. Thomas recommends moving the patient down to the 0.2% concentration earlier if there is rise in pressure, and the symptoms appear to be improving.
Once the patient has achieved control, it can be helpful to add an antihistamine/mast cell stabilizer or use one concommitantly to keep the symptoms at bay.2 In addition, the patient should use cold compresses, and consult with an allergist to learn about environmental modifications to avoid or decrease exposure to allergens and triggers in the home.
1. Kari O, Saari KM. Updates in the treatment of ocular allergies. J Asthma Allergy. 2010 Nov 24;3:149-58.
2. Melton R, Thomas R. Vernal keratoconjunctivitis. Clin Refract Optom. 2005;16(2):50-51.
