I

A COMPARITIVE STUDY OF EFFICACY, TOLERABILITY, SAFETY OF 0.03% TACROLIMUS EYE OINTMENT AND

0.05%CYCLOSPORIN EYE DROPS IN THE TREATMENT OF

VERNAL KERATOCONJUNCTIVITIS..

by

Dr. PADMINI S, MBBS

Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bengaluru

in partial fulfillment

of the requirements for the degree of

MASTER OF SURGERY

IN

OPHTHALMOLOGY

Under the guidance of

Dr. GOPINATH G S, MBBS, MS

Professor, Department of Ophthalmology

DEPARTMENT OF OPHTHALMOLOGY

MYSORE MEDICAL COLLEGE AND RESEARCH INSTITUTE

MYSORE – 570 001, KARNATAKA

MARCH 2019

VIII

LIST OF ABBREVIATIONS

AKC- Atopic keratoconjunctivitis

ANA – Antinuclear antibody

ADR – adverse drug reaction

CALT- Conjunctival associated lymphoid tissue

CO2 – carbondioxide

CsA- Cyclosporin A

ECP – Eosinophilic cationic protein

EPO- Eosinophil peroxidase

EPX– eosinophil protein X

GPC- Giant papillary conjunctivitis

GM-CSF – Granulocyte Macrophage-colony stimulating factor

HPA- Hypothalamo pituitary axis

IL – Interleukin

ICAM – Intercellular adhesion molecules

IgE– Immunoglobin E

IFN –Interferon

KC-Keratoconus

LDH – Lactate dehdrogenase

MMP– Matrix metalloproteinase

MCP – Monocyte chemotactic protein

MBP – Major basic protein

MPP-Mucus penetrating nano particles

IX

NAAGA– N acetyl aspartyl glutamic acid

RAST- Radio allegro sorbent test

RANTES- Regulated upon activation ,normal T cell expressed and selected

TGF – Transforming growth factor

TM – Trabecular meshwork

Th2 - T helper 2

TLR –Toll like receptor

VKC-Vernal keratoconjunctivitis

SICS – Small Incision Cataract Surgery

WK –Week

XII

LIST OF TABLES

Sl.

No.

Tables Page No.

1. Age distribution of VKC cases 60

2. Symmetric Measures 61

3. Genderwise distribution of VKC cases 62

4. Symmetric Measures 62

5. Itching scores in both the treatment groups during treatment period 64

6. Table 6:Chi-Square Tests 65

7. Photophobia changes in both the groups during treatment period 67

8. Chi-Square Tests 68

9. Watering scores in both the groups during treatment period 69

10. Chi-Square Tests 70

11. Bulbar hyperemia changes in both the groups during treatment period 71

12. Chi-Square Tests 72

13. Palpebral hyperemia scores in both the groups during treatment

period

73

14. Chi-Square Tests 74

15. Papillae scores in both the groups during treatment period 75

16. Chi-Square Tests 76

XIII

LIST OF FIGURES

Sl.

No. Figures

Page

No.

1 Cross section of conjunctival topography21

13

2 Palpebral VKC with giant papillae3 26

3 Papillae in limbal VKC3 27

4 Horner-Trantas dots3 28

5 Corneal shield ulcer35

29

6 Pseudogerontoxon37

31

7 Structures of dual action agents45

37

8 Hypothetical steroid induced cataract mechanism70

46

9 Concept of retrometabolic drug design 68

47

10 Retrometabolic design of cortienic acid based derivatives68

49

11 Structure of Loteprednol etabonate68

49

12 I care tonometer 101

13 Measurement of IOP 101

14 Bulbar hyperemia 102

15 Palpebral hyperemia 102

16 Papillae 103

XIV

LIST OF GRAPHS

Sl.

No. GRAPHS

Page

No.

1 Distribution of age in VKC cases 61

2 Gender wise distribution of VKC cases 63

3 itching scores in both the groups 66

4 Photobhobia changes in both the groups during treatment 68

5 Watering changes in both the groups during treatment period 70

6 Bulbar hyperemia changes during treatment period in both the

groups

72

7 Palpebral hyperemia scores in both the groups during treatment

period

74

8 Papillae scores in both the groups during treatment period 76

X

ABSTRACT

Background : Vernal keratoconjunctivitis(VKC) is a common ,chronic ,bilateral,

recurrent allergic inflammatory disease of the ocular surface, affecting mainly

young males in dry ,hot climate and country like India 1.

.Objectives : To compare the efficacy, tolerability and safety of 0.03% Tacrolimus

eye ointment and 0.05% cyclosporine eye drops in Vernal keratoconjunctivitis

Methods : This was a prospective study of 72 patients during December 2016 to May

2018. After detailed history and ocular examination all patients diagnosed to have

VKC and meeting inclusion criteria and exclusion criteria were included and divided

into 2 groups. Gp 1 was put on cyclosporine eye drops and gp 2 was put on

Tacrolimus eye ointment.cases were evaluated for signs, symptoms, IOP, and visual

acuity on first visit and subsequently at 6w, 12w,and 24wk.

Results: 72 patients were diagnosed to have VKC and divided equally into 2

grps.majority were males(),belonging to age group().both the gps showed significant

reduction in the symptoms and signs with not much difference in efficacy between the

groups and maintained normal IOP and visual acuity at 6w,12w, and 24w ..

Interpretation & conclusion: So in conclusion both the immunomodulators were

able to successfully resolve the signs and symptoms of VKC,were tolerable with no

significant adverse effects and much safer alternative to steroids as it caused no

elevation of intraocular pressure and steroid related complications.

Key Words : VKC; Cyclosporin eye drops ;Tacrolimus eye ointment; Intra Ocular

Pressure;

1

INTRODUCTION

Vernal keratoconjunctivitis(VKC) is a common ,chronic ,bilateral, recurrent allergic

inflammatory disease of the ocular surface, affecting mainly young males in dry

, hot climate and country like India 1.

Patients with VKC present with itching, redness ,photophobia ,ocular discomfort ,

foreign body sensation and lacrimation resulting in visual disturbances.2

The disease ranges in severity from mild to severe forms. Mild can still

interfere significantly with quality of life while severe cases are characterised

by potential impairment of vision. Especially if the cornea is involved.3

Duration of the disease is for about 6 years in patient`s with seasonal

incidence and for more number of years in perennial nature of disease.

VKC is generally treated with topical antiallergic agents, mast cell stabilisers ,

decongestants ,corticosteroids.3

Topical steroids are the conventional treatment for practically all severe kind of

allergic conjunctivitis. However, chronic use of topical corticosteroids may lead

to Glaucoma, Cataract and secondary infections. Inadequate counselling and

unrealistic expectations often result in overuse, misuse, and self use of steroid,

and it is not uncommon to see patients with steroid related complications.4

Additionally there is a subset of VKC patients that become refractory to the

corticosteroids treatment over a period of time4.

For refractory cases , oral or subtarsal corticosteroids are indicated, often resulting

in the aggravation of the lesion with tapering or discontinuation.

2

The risk of steroid induced ocular complications in VKC is particularly high in

children who are the most commonly affected age group resulting in loss of

school days and ultimately their future potential.5

Recently, immunomodulatory agents have been used to avoid steroid- related

complications. Tacrolimus suppresses Th2 lymphocyte activation, T helper cell-

mediated B-cell proliferation, and formation of cytokines.

Cyclosporin A is effective in controlling ocular inflammation by blocking Th2

lymphocyte proliferation and interleukin 2 production.

Not many studies are available in the evaluation of efficacy, tolerability, safety

of these immunomodulatory agents, hence the need for the present study.

3

OBJECTIVES

• To compare the efficacy, tolerability and safety of 0.03% Tacrolimus eye

ointment and 0.05% cyclosporine eye drops in Vernal keratoconjunctivitis.

4

REVIEW OF LITERATURE

Historical perspective

Arlt F was the first person to describe the limbal variety of VKC in 1846,

whereas the palpebral form of VKC was described about 25 years later in 1871 by

von Graefe.12

Von pirquet in 1906 described “allergy” as host reactivity to a

previously encountered antigen and in 1921 Prausnitz and Kustner showed that a

serum factor (IgE) was responsible for passive transfer of the allergic reaction to a

normal recipient.13

The association between exposure to airborne plant pollens and the

development of ocular and nasal symptoms in itself was noted by Charles Blackley in

1873.14

Arlt (1846) referred to VKC as conjunctivitis lymphatica while Desmarres

(1847) called it perikeratic hypertrophy. Von Graefe in 1871 was the first to

associate this “gelatinous perilimbal infiltrate” with pavement like proliferation of the

tarsal conjunctiva. Saemisch (1876) recognized it as a clinical entity and called it

spring catarrh. Camuset in 1874 published the first pathological investigation of VKC.

Various other names have been given to this condition during different periods of

time: phlyctena pallid (Hirschberg, 1871), circumcorneal hypertrophy (Burnett,

1881), recurrent vegetative conjunctivitis (Terson, 1902), conjunctivitis verrucosa

(Goldzieher, 1906), and so on. Herbert in 1903 stressed the importance of

eosinophilia. Axenfeld in 1907 gave an exhaustive pathological description. He

stressed the fact that there was a consistent failure in establishing the presence of

any characteristic bacterial flora. Trantas (1910) noticed the corneal complication.

Beigelman (1950) gave the most exhaustive and authoritative survey of this disease.

Rossi (1951) and di Ferdinando/Gattani (1957) advised topical steroids especially

5

in temperate climates as a treatment option. Jones (1961) used a prednisolone

solution rather than hydrocortisone suspension. Marton (1943) advocated

desensitization to an allergen to which the patient is particularly sensitive. Davidson

and Lawson (1909) were the first persons to use ionizing radiation with considerable

success in managing VKC. Iliff(1947) used beta radiation because of its greater

safety. Strebel (1933) froze the everted lids with CO2 snow spray and removed

exuberant vegetation with scissors and thermo-cautery. Excision and mucus

membrane grafting was first done by Goldstein in 1934. Pascheff’s histological

examination of the epithelium of the tarsal conjunctiva in VKC revealed a substantial

number of mast cells. VKC association with hay-fever was pointed out by Townsend

(1923), with vasomotor rhinitis by Mamoli (1930), and with asthma by Weinstein

(1930).15

Description of the condition

The phrase allergic conjunctivitis describes a group of clinically distinct

inflammatory conditions of the ocular surfaces including seasonal allergic

conjunctivitis (’hayfever’), perennial allergic conjunctivitis, atopic

keratoconjunctivitis and vernal keratoconjunctivitis. Atopic keratoconjunctivitis

(AKC) and vernal keratoconjunctivitis (VKC) are the most serious forms of allergic

conjunctivitis. These conditions are usually easy to distinguish, having characteristic

epidemiology (AKC has an older age of onset and is seen almost exclusively in

patients with atopic dermatitis) and clinical signs (giant papillae seen in VKC). A key

distinction is that VKC will usually become quiescent in the third decade whereas

AKC will not. Vernal keratoconjunctivitis (VKC) is a severe form of allergic eye

disease that predominantly affects male children (Bonini 2000; Leonardi 2002). The

disease is rare in Europe, with an estimated prevalence of 3.2 per 10,000 (Bremond-

6

Gignac 2008). It is more common in warmer climates such as the Mediterranean,

Africa, Asia and the Southern United States (Leonardi 2002; Resnikoff 1988). In

central Africa the prevalence of VKC in children has been estimated at 4% (Smedt

2011). Onset of disease is typically in the first decade. VKC is characterised by

symptoms of itch, photophobia, reduced vision and mucoid discharge. It is usually

seasonal, with acute exacerbations in spring and summer, and relative quiescence

between acute attacks, but a significant proportion of patients develop year-round

disease activity and hence a more chronic disease course. VKC primarily affects the

conjunctiva, the thin smooth layer of tissue covering the white of the eye ball and the

inside of the eyelids. It is characterized by conjunctival inflammation with formation

of large or giant papillae. It is usually bilateral, although the disease severity may be

asymmetric. VKC is classified according to which area of the conjunctiva is most

affected. It may affect the palpebral conjunctiva, which is the lining of the inside of

the eyelids, or the limbal conjunctiva, which is the covering of the eyeball near the

cornea (the clear window at the front of the eyeball). The pattern may also be a mix of

limbal and palpebral VKC.

Severe or protracted activity of limbal VKC may cause peripheral corneal

scarring. Severe or protracted activity of palpebral VKC may cause central corneal

scarring and significantly reduced vision. VKC is considered a type of atopic disease

and patients often have features typical of allergy such as raised serum IgE

(antibodies against allergen), the presence of eosinophils (a subtype of white blood

cell which is commonly seen in tissues affected by allergic inflammation) in

conjunctival biopsy specimens and a personal or family history of other allergic

diseases such as asthma or eczema. However, the pathogenesis is incompletely

understood. The cellular mechanisms appear to be more complex than just the typical

7

IgE-mediated Type-1 hypersensitivity reaction seen in seasonal allergic conjunctivitis

(hayfever) with increased recognition, in recent years, of a role for Tlymphocytes in

the process (Bonini 2004; Leonardi 1999; Leonardi 2002; Metz 1997). The condition

tends to improve after puberty and to regress as patients enter their twenties (Bonini

2000; Leonardi 2002). If it is not treated appropriately when it is active, VKC has the

potential to cause morbidity ranging from chronic ocular discomfort and photophobia,

loss of schooling to permanent visual loss from corneal scarring.

Description of the intervention

The spectrum of disease severity is wide. The factors to consider in deciding the

treatment strategy for each patient include the severity of the disease at its most

active, and the frequency of exacerbations. The therapeutic regimen should be tailored

for each patient (Sacchetti 2010). A number of topical treatment are used in VKC to

try to control disease activity. These include: • topical mast cell stabilisers; • topical

antihistamines; • topical dual-acting agents (drugs with both a mast cell stabilising and

an antihistamine effect); • topical steroid; • topical immunomodulatory agents (e.g.,

ciclosporin).

Topical steroid has potential side effects including cataract, glaucoma, and

enhanced secondary infection, whereas the other treatments listed above have few

serious side effects. Therefore the broad therapeutic aim is to control signs and

symptoms of VKC while using as little topical steroid as possible (Sacchetti 2010).

However, the control of severe exacerbations may require intensive application of

steroid drops which, apart from the risk of side effects, may cause practical difficulties

for young children and their parents. Patients whose VKC is quiescent or minimally

active between acute exacerbations are often treated with maintenance therapy using a

topical mast cell stabiliser or a dual acting agent. Topical mast cell stabilisers are the

8

most commonly used maintenance therapy. They increase the threshold stimulus for

mast cell degranulation in the conjunctiva. Their mechanism of action is not well

understood. Some patients with a more severe or chronic course are treated with low-

dose maintenance topical steroid or topical ciclosporin.

The symptoms and signs of VKC, like all inflammatory conditions, are caused

by release of mediators from resident white blood cells in the tissues or the

interaction with the tissue by infiltrating activated white blood cells from the blood, or

both. The interventions to be studied in this review all interfere with or inhibit some

action of white blood cell function. The types of white blood cell seen in the

conjunctiva during active VKC include; mast cells, neutrophils, eosinophils,

macrophages and monocytes, T lymphocytes and dendritic cells. Some of the

interventions are more specific for white blood cell subtypes than others. For example,

topical steroids are known to have effects on neutrophils, monocytes, dendritic cells

and T lymphocytes whereas mast cell stabilisers specifically inhibit mast cell

degranulation in response to allergen (by mechanisms that are, as yet, poorly

understood

Epidemiology

Geographic distribution

VKC has a wide geographical distribution. But the prevalence varies among

different ethnic groups. It is primarily seen in dry and hot climates. It is more

common in temperate zones of Mediterranean areas, central and West Africa, the

Middle East, Japan, the Indian subcontinent and South America. VKC is also

observed in Western Europe (including the UK and Sweden), Australia and North

America – albeit this prevalence may be compounded in view of migration of

susceptible populations to these regions. In some areas like east Jerusalem, the West

9

Bank and Gaza, VKC is a leading cause of outpatient ophthalmic morbidity after the

decline of endemic trachoma.5

VKC is characterized by giant papillae found in either the upper tarsal

conjunctiva or at the limbus, the tarsal form predominates in white patients whereas

the limbal form is commoner in African and Mediterranean patients.14

Though warm weather facilitates development of VKC, even areas like Japan

which has a milder climate reports large number of cases of VKC, hence warm

weather conditions may not be absolutely necessary for the development of the

disease. While the population prevalence of VKC among African children was found

to be as high as 4%, the same in Europe is in the range of 1:30,000–1:80,000. These

differences in prevalence is probably due to the diversity of genetic make ups,

environment (climate, socioeconomic status, and living styles), and gene–

environment interaction. Atopic sensitization has been found in around 50% of

patients suffering from VKC. The type of allergens sensitized in VKC patients is

different in different geographic regions. In the Mediterranean, most patients are

sensitized to seasonal allergens, such as rye grass pollens and Parietaria, and therefore

suffer from a more severe disease in the spring and autumn. However, in the tropics,

house dust mites are the most common allergens causing sensitization, followed by

cockroach and grass pollens.16

The patients with VKC living in milder climates like Europe tend to have a

milder form of the disease and the prevalence of associated corneal complications is

much lower (0.3-2.3 per 10,000 population).17

10

Seasonal variations and Age and sex distribution

The usual age of onset of VKC is before 10 years of age. The earliest known

reported age of onset is as early as 5 months. It generally resolves after puberty, after

a disease duration of 4–10 years after onset. The disease is commoner in males, with

the male to female ratio varying from 4 : 1 to 2 : 1 depending on the locality and

study. This male preponderance is appreciated only below 20 years of age but after 20

years, the male and female ratio becomes almost equal. Experimental evidence for the

presence of oestrogen and progesterone receptors in conjunctiva in patients of VKC,

the male preponderance of the disease and usual resolution after puberty point

towards hormonal factors having a role in the development of VKC.13

Regardless of its name suggesting it to be seen predominantly during spring

and summer months, VKC can be frequently present all year round. Approximately

23% of patients have a perennial form of VKC from disease onset itself and more

than 60% have additional recurrences during the winter. In about 16% of the cases,

the seasonal (vernal) form evolves into a chronic, perennial inflammation after a mean

duration of 3 years from disease onset, suggesting that over time the disease though

beginning as a seasonal form turns into perennial in character.18

Vernal catarrh or vernal keratoconjunctivitis (VKC) comprises 0.5% of

allergic eye diseases. The incidence of the disease tends to peak in spring owing to

increased exposure to tree grass pollens, therefore extrinsic elements also contributing

to the disease.14

Due to various reasons, patients often suffer the affliction for 3–4

years before being properly diagnosed.16

Allergen exposure need not necessarily be the cause for VKC, exposure to

nonspecific stimuli–such as wind, dust and sunlight and the resulting hyperreactivity

11

can cause the ocular symptoms. Indeed, skin tests and/or serum IgE antibody tests to

common allergens are often negative in people having VKC.17

Role of genes in VKC

Though no genetic predisposing factor has yet been identified for

susceptibility to VKC, but the fact that this disease is predominantly seen in Asia and

Africa, and this trend continues even in families of these regions which have migrated

to cooler regions, hints at the possibility for genetic predisposition. In fact VKC is

more common among individuals of Asian and African origin living in Sweden. The

constant and increased presence of eosinophils in blood, tears and conjunctival

scrapings, the expression of a multitude of mediators and cytokines, as well as the

predominance of CD4 cells locally, point in the direction that VKC may be a

phenotypic model of upregulation of the cytokine gene cluster on chromosome 5q.

This cytokine gene cluster, through its products like Interleukin (IL)-3, -4, -5 and

granulocyte/macrophage colony-stimulating factor (GM-CSF), regulate the

prevalence of T helper cell type 2 (Th2), the growth and function of mast cells and

eosinophils as well as the production of immunoglobulin (Ig) E in VKC. Also since

family history of allergic disorders such as asthma, rhinitis, eczema, urticaria and

multiple atopic diseases are reported in 49% of patients suffering from VKC ,

therefore a yet be identified genetic predisposition is a possibility.5

Associated conditions

Many associations have been found to be linked to VKC, some of them strong

while others are tenuous. Atopy is the presence of allergen-specific IgE antibodies

and is seen in quite a few VKC patients. One third of VKC patients exhibit multiple

atopic diseases and asthma being the most common atopic disease seen among VKC

12

patients. Atopy is less common in limbal type compared to tarsal variant VKC. Sex

hormone-related diseases such as gynaecomastia, polycystic ovary syndrome,

mammary fibroadenoma, adiposogenital dystrophy and autoimmune diseases are

reported by 2% of patients suffering with VKC.

There has also been a correlation between eyelash length and severity of VKC.

The hypothesis for this being that long lashes may serve as a protective mechanism

against physical agents that might have an important role in the aetiopathogenesis of

VKC, although the chemical mediator responsible for lash growth has not been

identified.

Fifteen per cent of VKC patients are reported to have keratoconus; 6% of

these developed hydrops. A higher incidence of keratoconus and acute hydrops

among VKC has been ascribed to excessive eye rubbing, but it may also be a result

due to a complex interaction between hereditary and environmental factors directed

against the cornea in a susceptible population.5

It has been observed that 1 in 4

patients with VKC have topographic corneal change of the corneal anterior surface

related to keratoconus, undetected by the clinical examination. The mean anterior

corneal curvature of patients with VKC was more accentuated than in the control

group. This has been attributed to the persistent and chronic corneal trauma on the

corneal epithelium (due eye rubbing to counteract itching or chronic trauma provoked

by giant papillae), inducing a chronic inflammatory process, leading to progressive

loss of stromal mass and consequently to less biomechanical resistance, and thus to

anterior corneal steepening.19

Additionally a family history of autoimmune disorders like Hashimoto’s

thyroiditis, type I diabetes, psoriasis and Systemic Lupus Erythematosus have been

13

shown in a large number of VKC patients. Also, 35% of patients showed ANA

positivity and such patients had a more severe form of VKC.20

Conjunctiva

The conjunctiva is a vascular mucous membrane covering the anterior part of

the globe and the inner surfaces of the eyelids. The word “conjunctiva” is in all

probability derived from the Latin word conjugation meaning joining together or

blending. The upper and lower pockets formed from the reflection of the conjunctiva

onto the globe from the inner surface of the lids is respectively called as the superior

and inferior fornices.21

Depending on the location the conjunctiva is called as bulbar

and palpebral conjunctiva.

Figure 1 : Cross section of conjunctival topography21

14

Bulbar conjunctiva

This covers the anterior part of the globe and is loosely attached to the globe

and easily moves when pushed with a cotton tipped applicator. In fact it is this loose

attachment which makes it possible for creation of filtering blebs for treatment of

glaucoma. Under normal conditions it is quite transparent with traces of vasculature,

until and unless it becomes irritated.21

The dimensions of the bulbar conjunctiva varies in different parts of the globe.

Superiorly the chord length of the conjunctiva from the limbus to the fornix is

between 13-16mm. Inferiorly it is between 10-12mm, whereas temporally it is about

12 mm and a significant part lying behind the lateral canthus. The least is on the

medial side due to the presence of the caruncle and the medial wall of the orbit.22

Palpebral conjunctiva

The palpebral conjunctiva in contrast to the bulbar conjunctiva is firmly

attached to the tarsal plate of the eyelids. It can be visualized by pulling the lower lid

down and by everting the upper lid. This part of the conjunctiva is the site for two

common pathologic changes namely follicles and papillae.21

It extends from the mucocutaneous junction of the eyelid margin. It is further

subdivided into marginal, tarsal and orbital parts. The marginal part is roughly 2 mm

wide, where the transition from nonkeratinized stratified epithelium of the eyelid

margin to the cuboidal epithelium of the tarsal conjunctiva takes place. The tarsal

conjunctiva as previously mentioned is firmly adherent to the tarsal plate and this is

essential as it has an intimate relationship with the cornea. The orbital conjunctiva

extends from the edge of the tarsal plate to the fornix.22

The surface of the orbital

conjunctiva is thrown into folds when the lids are open, whereas they disappear on

closure of the eyelids.23

15

Conjunctival epithelium

The conjunctival epithelium is made up of stratified squamous epithelium,

which rests on a loose connective tissue called as substantia propria. The morphology

and thickness (number of layers) of the epithelium varies according to the region.23

The epithelium of the bulbar conjunctiva is more than six layers thick and is

predominantly made up of cuboidal cells. Around the fornix the epithelium is

typically three layers thick, the superficial layer is made up of cylindrical cells, the

middle layer of polyhedral cells and the deep layers has cuboidal cells. The palpebral

conjunctival epithelium makes the transition from keratinized epithelium of the eyelid

to the nonkeratinized variety at the lid margin. Similar to the bulbar conjunctiva, it is

also made up of cuboidal cells. The thickness of the epithelium varies from as low as

2-3 layers over the upper tarsal region to as high as 4-5 layers near the lower tarsal

region.22

Substantia propria

The substantia propria is located below the epithelial basement membrane

(which is made up of predominantly type IV collagen fibers). In the bulbar

conjunctiva it is a highly vascular/loose connective tissue and near the limbus it is thin

and compact. The substantia propria is comparatively thicker near the fornix and is

made up of two layers: a superficial lymphoid layer and a deeper fibrous layer. The

superficial layer has a variety of cells like lymphocytes (mainly T lymphocytes), mast

cells plasma cells and neutrophils. The deeper layer contains the vessels, nerves and

the glands of Krause. Medially this tissue is modified into two structures namely the

plica semilunaris and the caruncle. In the palpebral conjunctiva the substantia propria

is thin, compact and firmly attached to the tarsal plate.22

The superficial lymphoid

16

layer is not present at birth, but develops 3 to 4 months afterwards. This layer stops at

the subtarsal fold and therefore is absent in the marginal conjunctiva.23

Goblet cells

These are interspersed within the conjunctival epithelium. They are apocrine

in nature and constitute 5-10% of the epithelial basal cells in the bulbar conjunctiva.

The highest density of these goblet cells are found in the inferonasal bulbar

conjunctiva and the tarsal conjunctiva.22

But they are absent in the marginal and

limbal conjunctiva. They are present in high density in children and decreases with

age up to the fourth decade after which the numbers are constant. They form clusters

in the bulbar conjunctiva, but are present singly in the fornical regions. The number of

goblet cells tends to increase in inflammatory conditions, while the normal goblet cell

count is 8.84 + 4.66 cells per sq mm.23

Glands of the conjunctiva

Apart from the goblet cells the conjunctiva is also dotted with various other

glands like: Krause’s glands, Glands of Wolfring or Ciaccio, Henle’s glands and

Manz glands. The Krause’s and Wolfring glands are accessory lacrimal glands whose

microscopic structure is similar to the main lacrimal gland. There are 40-42 Krause’s

glands in the upper fornix and 6-8 glands in the lower fornix. Whereas in case of

Wolfring glands there are 2-5 glands in the upper lid and 2 glands in the lower lid.

The Henle’s glands are folds in the palpebral conjunctiva between the tarsal plate and

the fornix, while the Manz glands are saccular/utricular structures found at the

limbus.23

17

Embryology of the conjunctiva

It is derived from the surface ectoderm and can be distinctly distinguished

from that of skin and the cornea as early as the 10th gestational week, corresponding

to the 40-45mm stage. The goblet cells are found frequently at the 12th

gestational

week (60-70 mm stage), but may be found earlier in the fornical regions.24

Blood supply of the conjunctiva

The blood supply to the bulbar conjunctiva is derived mainly from the anterior

ciliary arteries and the peripheral tarsal arcades of the eyelid. They ultimately form an

arteriolar plexus near the limbus. The venous drainage is via the anterior ciliary veins,

conjunctival veins and finally through the eyelids venous plexuses to the inferior and

superior ophthalmic veins.

The palpebral conjunctiva has dual blood supply. The principal vascular

supply comes from the branches of the ophthalmic artery namely: dorsal, nasal,

frontal, supraorbital and lacrimal arteries. Additional blood is supplied to the

palpebral conjunctiva via the branches of the facial artery namely: facial, superficial,

temporal and infraorbital branches. Drainage of impure blood occurs through post

tarsal veins of the eyelids, deep facial branches of the anterior facial vein and the

pterygoid plexus.22

The conjunctival congestion seen in conjunctivitis is due to the

anterior and posterior conjunctival arteries.23

The conjunctival vessels move with the

conjunctiva and constrict on instillation of 1:1000 epinephrine, which helps in

differentiation from the deeper episcleral and ciliary vessels.25

Lymphatic drainage of the conjunctiva

Lymphatic drainage from the bulbar conjunctiva follows different routes

depending on the part of the bulbar conjunctiva. The nasal side drains into the

18

submandibular nodes, while the temporal part drains to the preauricular nodes. The

fornical part of the conjunctiva follows a similar lymphatic drainage pattern. That of

the palpebral conjunctiva is via the eyelid lymphatics to the submandibular and

preauricular nodes.22

Nerve supply to the conjunctiva

The bulbar, fornical and palpebral conjunctiva have afferent sensory

innervation via the various branches of the ophthalmic division of the fifth cranial

nerve (Trigeminal nerve) namely: lacrimal, supraorbital, supratrochlear and

infraorbital branches. In addition the medial fornical conjunctive also has sensory

nerve supply from the maxillary division of the trigeminal nerve.22

Immunology of the conjunctiva

The conjunctiva has an armamentarium of defense mechanisms which

includes an intact epithelium, lysozyme, immunoglobulins and lactoferrin. It consists

of an innate, adaptive and mucosal immunological mechanisms. T cells are found

both in the conjunctival epithelium and the substantia propria, whereas B lymphocytes

are rarely found in the substantia propria. There is also the possible existence of a

specific mucosal immune system called as conjunctival associated lymphoid tissue

(CALT).22

Glossary of terms pertinent to the conjunctiva21

Chemosis: Swelling or edema of the bulbar conjunctiva.

Conjunctivitis: Inflammation of the conjunctiva, which can be caused by infectious

agents or allergens. Symptoms can include redness, irritation, swelling, discharge and

photophobia.

19

Follicles: Clear, oval mounds on the palpebral conjunctival surface (most frequently

the lower lid surface) that indicates ocular irritation, allergic response or viral

lymphocytic reaction.

Papillae: Fine, hyperemic elevations commonly on the palpebral conjunctival surface

of the upper lid and associated with inflammation and infection.

Pathophysiology

Although VKC is classified as an allergic disease, it does not conform to the

classical type I IgE-mediated disease. In fact, skin tests and RAST (radio allegro

sorbent test) are often negative in VKC and several patients do not have a personal or

family history of atopy, rather it is a Th2-driven mechanism at play. Supporting this

definition are the findings that T-cell clones derived from VKC tissues are mainly of

the Th2- type and that in the CD4 areas of VKC biopsies, there is an increased in situ

hybridization signal for IL-5 associated with increased IL-5, but not IL-2, levels in

tears, suggesting Th2 rather than Th1 activity. Therefore the pathogenesis of VKC is

characterized by a Th2 lymphocyte alteration, while the exaggerated IgE response to

common allergens is an inconsistent finding and if found it is probably a secondary

event. Th2 lymphocytes themselves are responsible both for hyperproduction of IgE

(IL-4) and for differentiation and activation of mast cells (IL-3) and eosinophils (IL-

5).18

Th2 response

T lymphocytes are a major source of cytokines. Those expressing CD4 are

also known as helper T cells, and these are regarded as being the most important cells

for cytokine production. This subset can be further subdivided into Th1 and Th2, and

the cytokines they produce are known as Th1-type cytokines and Th2-type cytokines.

20

Th1-type cytokines tend to produce the proinflammatory responses responsible for

killing intracellular parasites and for perpetuating autoimmune responses. Interferon

gamma is the main Th1 cytokine. Excessive proinflammatory responses can lead to

uncontrolled tissue damage, so there needs to be a mechanism to counteract this. The

Th2-type cytokines includes interleukins 4, 5, and 13, which are associated with the

promotion of IgE and eosinophilic responses in atopy, and also interleukin-10, which

has more of an anti-inflammatory response. Allergy is usually considered to be due to

an imbalance between these two responses, favoring the Th2 response.26

Cells in VKC

The epithelium of normal subjects contain neutrophils and lymphocytes but

not plasma cells, eosinophils, mast cells, or basophils. All these cells are found in the

conjunctival epithelium of the vernal conjunctivitis patient.27

Conjunctival Epithelial Cells

Conjunctival epithelial cells play an active role in ocular allergy. They have

receptors for, and respond to, proinflammatory cytokines and, via production of

cytokines, also regulate inflammation at the ocular surface. In VKC, an increase in

TLR-4 (Toll like receptor) expression by conjunctival and corneal epithelium has

been observed.28

ICAM-1, HLA-DR, IL-3 and GMCSF are not normally expressed in

conjunctival epithelium but these antigens are induced on conjunctival epithelial cells

in VKC. RANTES, though present in normal conjunctival epithelial cells, is

upregulated in VKC. ICAM-1 allows epithelial cells to recruit, retain and locally

concentrate leukocytes. The upregulated epithelial cytokines promote an eosinophilic

inflammation.5

21

Conjunctival goblet cells

Most types of allergic conjunctivitis are characterized by increased mucus

secretion, although the characteristics of this ocular mucus can vary between types of

allergic conjunctivitis. Histamine is an important mediator released in allergic

conjunctivitis and it acts via G protein-linked receptors (H1, H2, H3, and H4). It has

been demonstrated that: All four histamine receptors are present and active in

conjunctival goblet cells and these cells respond to histamine produced during

allergic conjunctivitis to secrete mucus.28

Mast cells

The mast cells are the key players in allergic eye diseases, this is amply clear

as large numbers of mast cells are found in tissue samples from tarsal giant papillae.

These cells express Fc [epsilon] RI on their cell surface, which enables them to bind

IgE, whose cross linkage ultimately results in the release of pro-inflammatory

mediators like histamine, proteases, prostaglandin D2 and leukotriene C4. These

mediators are responsible for causing ocular itching, hyperaemia, lacrimation and

chemosis in allergic conjunctivitis. Mast cells are classified based on their protease

content into containing only tryptase in their granule, known as MCT, and that

containing both tryptase and chymase, called MCTC. Normally about 80% of

conjunctival mast cells are of MCTC type. The MCT type is increased in conjunctiva of

VKC patients. They are also capable of synthesizing IL-4, which has a role in

eosinophil infiltration in VKC. Tryptase and chymase, indicators of mast-cell

activation, are increased in tears and may serve as sensitive markers for determining

the severity of VKC.5

The critical role played by mast cells in the pathogenesis of

22

ocular allergy, is demonstrated by the absence of symptoms in mast cell-deficient

mice in an experimental allergic conjunctivitis model.28

Eosinophils

Conjunctival biopsies of VKC patients show large number of eosinophils

which are detectable both by light microscopy as well as by immunohistochemistry.

Eosinophils are increased in both bulbar and tarsal conjunctiva. In VKC they are

detected not only in the subepithelium but also in the epithelium, where no eosinophil

are generally present in normal persons.29

VKC is the only ocular surface disorder in which greater than two eosinophils

can be found per 25-power objective field.27

Nearly 50–90% of the cells observed in

the tears during the active phase of VKC are eosinophils. Eosinophils, along with

mast cells, are the main effector cellular elements responsible for ocular inflammation

in VKC. Numbers of eosinophils are increased significantly not only in the tears but

also in the peripheral circulation and conjunctival tissue from VKC patients. The

tears, conjunctiva and the periphery of corneal ulcers in VKC patients have not only

the degranulated eosinophils, but also the contents of these granules like eosinophil

cationic protein (ECP) and eosinophil major basic protein (MBP), thus demonstrating

the significant role played by eosinophils in the aetiopathogenesis of VKC. Many

chemical agents are responsible for this increase in eosinophils, Eotaxins are potent

chemoattractants, which recruit and activate eosinophils in VKC, while IL-5 induces

eosinophil differentiation, recruitment, activation and survival. These activated

eosinophils release cytokines, chemokines, leukotrienes and epitheliotoxic proteins

such as MBP, ECP, eosinophil peroxidase (EPO) and eosinophil protein X⁄neurotoxin

(EPX). The tear and serum levels of ECP and EPX are found to be higher in VKC

patients in comparison to normal subjects. ECP tear levels correlate positively with

23

clinical signs and symptoms of VKC and promptly reduced on initiation of treatment

with dexamethasone or cyclosporine. In fact tear levels of ECP have been used to

evaluate the efficacy of drugs in the treatment of VKC. Eosinophil MBP deposition,

found in corneal ulcers of VKC patients, suggests the direct deleterious effects of this

eosinophil protein on corneal epithelium.5 Eosinophils gelatinase B and polycationic

toxic proteins like major basic protein and eosinophilic cationic protein, in vitro

studies have been shown to cause epithelial damage and desquamation.30

B lymphocytes expressing the ligands CD23, 21 and 40 and Natural killer

cells are other types of cells which are increased in number in patients of VKC.5

Mediators in VKC

Cytokines are small secreted proteins that mediate and regulate immunity and

inflammation. ILs (interleukins) are the cytokines that are made by leukocytes and act

on other leukocytes. Th2 cytokines, i.e. IL-4 and -5, are increased in VKC patients.

The serum levels of IL-4 and tear levels of IL-4 and IL-5 are increased in VKC.

Whereas IL-2, interferon (IFN)-gamma and tumour necrosis factor (TNF)-b, the Th1

cytokines, are not.

Chemokines are potent activators and chemoattractants. They are produced by

a wide variety of cells like inflammatory cells, stimulated epithelial cells, fibroblasts

and vascular endothelial cells in the conjunctiva. Apart from leukocyte recruitment

these multipotent cytokines also localize and enhance inflammation by inducing

chemotaxis and cell activation of different types of inflammatory cells present at sites

of inflammation. Eotaxin, along with MCP (monocyte chemotactic protein) and

RANTES (regulated upon activation, normal T cells expressed and secreted) are

chemokines which are highly expressed in limbal tissues and are responsible for the

24

massive eosinophil infiltration. IL-8 and monokine induced by interferon gamma

(Mig), may also have a significant role in the pathogenesis of VKC.

Other mediators like histamine, metalloproteinases (like MMP-1 and MMP-9)

and several growth factors, such as epidermal growth factor, fibroblast growth factor,

nerve growth factor and transforming growth factor beta-1 (TGFb-1), are also

increased in VKC and hence suggesting a role in its pathogenesis.5

Clinical features and diagnosis

The clinical classification of vernal keratoconjunctivitis (VKC) into limbal,

palpebral and mixed types of the disease was established by Emmert in 1888. Limbal

VKC is differentiated from palpebral VKC by the development of papillae at the

limbus without giant papillary formation on the tarsal conjunctiva. The palpebral form

on the other hand is characterized by giant papillae on the upper tarsal conjunctiva

without the limbal papillae. Patients showing both giant papillae as well as limbal

papillae are classified as mixed type.31

The tarsal form of VKC is the most common type seen in 44-83% of the

patients, the limbal variety is seen in 8-11%, whereas the mixed variety is seen in 9-

46% of patients. The most common features of vernal keratoconjunctivitis, which are

seen in almost 90% of the cases are, itching, redness, photophobia and tearing.32

The

other symptoms include foreign body sensation, ptosis, thick mucus discharge and

blepharospasm. The signs are limited to the conjunctiva and cornea, while the lids and

lid margins are usually uninvolved unlike in atopic keratoconjunctivitis (AKC). The

conjunctiva develops a papillary response mainly of the upper tarsus and the limbus.

This along with the thick, ropy mucous that is usually found with the tarsal papillae

forms the classical “cobblestone papillae”.33

25

The raised conjunctival cobblestones are almost never seen over the lower

plate. Bulbar conjunctival cobblestones, papules, or follicles are also rarely seen. The

cobbles are large and pleomorphic, and usually unevenly distributed. These cobbles

differ from those in GPC by being dramatically larger in height and breadth and

varying in shape, than the homogeneous cobbles seen in GPC or in the follicles in

viral conjunctivitis. Scarring is not present, irrespective of VKC disease duration. If

scarring exists, it is more suggestive of the Arlt lines found in trachoma. The

cobblestones in VKC represent collagen proliferation, increase in ground substance

and cellular accumulation. The development of ptosis in VKC is either due to the

presence of keratitis and photophobia, producing a protective response or also due to

increased bulk of upper tarsal conjunctiva or myositis of the levator muscle.27

The

tarsal papillae are usually present even when the disease is quiescent, but tend to

become hyperemic and edematous when the disease flares up.34

The tarsal papillae are discrete and greater than 1mm in diameter with

flattened tops that may stain with fluorescein and are more common in those from

Europe or North America. Whereas limbal papillae tend to be confluent and

gelatinous and are more common in African patients.33

Gelatinous, translucent,

globular deposits at the limbus vary greatly in size and shape, from a 2 mm circle to

an arc to a 360° ring. The gelatinous nodules of limbal VKC are vascular and rapid in

onset and respond promptly to topical steroids, factors that differentiate these from

other limbal tumors.27

Horner–Trantas dots, which were described in the 1880s, are chalk-white,

raised superficial infiltrates straddling the limbus with no specific meridional

predilection, unlike the immune marginal infiltrates, which have a surrounding lucid

26

area, involve the corneal stroma, and are separated from the limbus by ∼1 mm.27

They

are collection of epithelial cells and eosinophils.33

Abundant, firm cordlike mucus with highly elastic properties is always present

in VKC. Mucus production is characteristic of many forms of allergic conjunctivitis,

but it is more abundant in VKC. The mucus in VKC differs in consistency from the

thin strands normally seen in other forms of allergic conjunctivitis. The thick,

tenacious, ropy strands have an elastic quality described as the Maxwell Lyon sign.

This chewing gum-like mucus contains inflammatory cells, specifically, large

numbers of eosinophils and Charcot–Leyden granules. Mucopolysaccharides,

possibly hyaluronic acid, have been found in the mucus. In some of the patients, the

pH of the mucus is highly alkaline. Such high tear pH values are found only in severe

rosacea keratitis.27

Figure 2 : Palpebral VKC with giant papillae3

27

Itching is a characteristic feature of all allergic diseases. But, the intensity of

the itching seen in patients with VKC is severe enough to require vigorous knuckle

rubbing, and this observation is very typical of this disease. The pattern of

vasodilatation seen in VKC is unremarkable and it gives the conjunctiva a pink color

rather than the red observed in severe corneal ulcers and infectious conjunctivitis.

Mild to moderate chemosis, sometimes visible only with a slit-lamp as a pinkish fluid

slightly separating the conjunctiva from the underlying episclera, is commonly seen in

VKC, rather than the ballooning chemosis of acute conjunctivitis.27

Figure 3 : Papillae in limbal VKC3

28

Figure 4 : Horner-Trantas dots3

Corneal complications

Abnormalities of the cornea are most often seen in the tarsal form of VKC,

and they tend to be usually limited to the superior and central cornea.34

The different

manifestations of corneal involvement among patients with VKC vary from

superficial punctuate keratitis, shield ulcer, corneal plaque, bacterial or fungal

keratitis, keratoconus, hydrops, pseudogerontoxon and corneal opacification. Punctate

epithelial keratitis may coalesce to form a frank corneal epithelial defect, known as

shield ulcer. If left untreated, a plaque containing fibrin and mucus is deposited over

the epithelial defect. Shield ulcers without plaque formation usually undergo rapid re-

epithelialisation, resulting in an excellent visual outcome, however, patients with

shield ulcers and visible plaque formation have delayed re-epithelialisation. Tear film

instability seen in the later stages of VKC is another important factor which adversely

affects the reepithelialisation of shield ulcer.

29

Cameron classified shield ulcers on the basis of their clinical characteristics,

response to treatment and complications as follows:

Grade 1 - Shield ulcers having a clear base; these have a favorable outcome

and re-epithelialise with mild scarring.

Grade 2 - Ulcers with visible inflammatory debris in the base; such ulcers are

prone to complications and exhibit delayed reepithelialisation and a poor

response to medical therapy.

Grade 3 - Shield ulcers with elevated plaques; these respond best to surgical

therapy.35

The pathogenesis of these shield ulcers is believed to involve a combination of

mechanical damage to the corneal epithelium from giant papillae, as well as toxic

epitheliopathy from inflammatory mediators secreted by eosinophils and mast cells.36

Figure 5 : Corneal shield ulcer35

30

Pseudogerontoxon is a local lipid deposit in the peripheral cornea, occurring in

patients with a history of allergic eye diseases, like VKC. These opacities appear

similar clinically to the corneal arcus (gerontoxon), hence the name

pseudogerontoxon. The lipid deposit in pseudogerontoxon is thought to occur as a

result of prolonged limbal infiltrates and increased limbal permeability accompanying

VKC, in contrast to the elevated serum lipid levels in corneal arcus. The finding of

pseudogerontoxon is indicative of the presence of current or previous ocular allergic

disease and in fact may be the only ocular sign of this ocular allergic history.37

Keratoconus (KC) is a bilateral, non-inflammatory, progressive condition

associated with corneal ectasia. The thinning and protrusion of the cornea causes

progressive myopia and irregular astigmatism especially after puberty. Its occurrence

in relation to chronic VKC is noted in the literature. Chronic ocular trauma has been

identified as an important environmental factor that leads to the development of KC in

genetically predisposed individuals. In atopic individuals, faster progression of KC,

early need for surgery and more often surgical and immunologic complications is

observed. The tissue damage could be caused by chronic corneal epithelial trauma due

to giant papillae and/or eye rubbing, resulting in prolonged, slow release of small

amounts of degradative enzymes called matrix metalloproteinases (MMP).38

31

Figure 6 : Pseudogerontoxon37

Diagnosis

The typical and characteristic signs and symptoms of VKC makes the

diagnosis straightforward. Atypical presentations or incomplete forms of VKC may,

however, lead to an underestimation of its incidence. The identification of both the

major and minor signs and symptoms of VKC allows an early and accurate diagnosis

of this disease. The usefulness of total and specific IgE determination, as well as skin

tests are not of much use, since more than half of VKC patients are negative for it. In

case of a diagnostic dilemma, a conjunctival scraping can be performed to

demonstrate the presence of eosinophils infiltrating the conjunctival epithelium.18

32

Treatment modalities

Non Pharmacological approach

Providing the patient and their parents (in case of minors) the complete details

regarding the characteristics and probable complications of the disease would be

helpful for the affected persons to cope with the disease. In severe cases psychological

support would also be an essential part of the treatment. The following non

pharmacological strategies may offer some amelioration of the signs and symptoms of

VKC:39

The most basic aspect while treating VKC would be the identification of

allergens and avoidance of those environmental factors that may exacerbate

the disease.

Avoiding exposure to nonspecific triggering factors, such as sun, wind, and

salt water, with the use of appropriate protective gear should be suggested.

Frequent hand, face, and ear washing would also be necessary as this reduces

the exposure to allergens.

Cold compresses may serve as natural decongestant and provide some relief.

Tear substitute’s aid in stabilization of the tear film, act as an eyewash, and

dilute the concentration of the allergens and mediators in tears, thereby

reducing the signs and symptoms of VKC

Eye drops containing herbal extracts, such as chamomile-containing

preparations, should be avoided because they may cross-react with sensitizing

allergens.

Avoid rubbing itchy eyes, as this makes the condition worse.

33

But the eyes present a large surface area and thus it is often difficult to avoid

ocular exposure to airborne allergens. In such circumstances where non-

pharmacologic strategies don’t translate into adequate symptom relief, pharmacologic

treatments either topically or systemic have to be resorted to achieve amelioration of

symptoms.17

Vasoconstrictors

Ocular allergic diseases spanning all forms and severity are characterized by

hyperemia, which is mainly due to the release of histamine. This condition can be

improved by the use of vasoconstrictors. This class of drugs provide symptomatic

relief to the patients by reducing conjunctival edema and hyperemia. They produce

their actions by activating the postjunctional alpha adrenergic receptors located on

pre/postcapillary blood vessels, resulting in constriction of the conjunctival vessels

and the subsequent reduction in hyperemia and edema. The low concentration of the

drugs that are required to produce this effect on topical application does not cause

pupillary dilation. Another advantage of this class of drugs is that they can be

combined with other therapeutic agents like antihistamines. The commonly used

topical vasoconstrictors include naphazoline, tetrahydrozoline, phenylephrine, and

oxymetazoline. Burning or stinging on installation and rebound hyperemia are

common side-effects with these drugs.40

Mast cell stabilizers

Mast cells are the centerpieces in the occurrence of allergic diseases because

of their hypersensitive response to otherwise innocuous substances that induces an

allergic reaction. This happens when there is an interaction of allergen with

polyvalent IgE–FceRI complexes expressed on the surface of sensitized mast cells

34

that causes receptor aggregation. This is followed by activation of signaling cascades

ultimately, leading to calcium influx and release of preformed chemical mediators

such as histamine from mast cells, as well as the synthesis of lipid mediators such as

PGs and LTs and the production of cytokines and chemokines. These mediators cause

recruitment of other immune cells which are responsible for the early and late effects

of an IgE-mediated allergic reactions.

Hence mast cells are key players in both the development and maintenance of

allergic diseases and hence they are the natural primary targets in the management of

allergic diseases like allergic conjunctivitis.41

The drugs in this group include sodium cromoglycate , lodoxamide ,

nedocromil and pemirolast and they are used as the first line of defense at the onset

of the allergic season and should be used continuously throughout the season.5

The recommended dosing schedule for these class of drugs is 4–6 times daily,

with a loading period of at least 7 days and an onset of activity takes as much as 2

weeks. Nedocromil is more potent than disodium cromoglycate (DSCG), as it acts on

multiple cells involved in allergic inflammation, including eosinophils, neutrophils,

macrophages, mast cells, monocytes, and platelets. The mechanism of action of

lodoxamide is similar to that of DSCG, but is more effective than DSCG for the

inhibition of eosinophil activation, as evaluated by measuring tear eosinophil cationic

protein ECP before and after therapy. Hence lodoxamide has an effect on eosinophil

activation. Inhibition of eosinophil activation and degranulation is the probable

mechanism for its efficacy against corneal signs such as keratitis and shield ulcers in

severe allergic disease.

35

Another mast cell stabilizer N-acetyl aspartyl glutamic acid (NAAGA) used as

a 6% formulation inhibits leukotriene synthesis, histamine release by mast cells, and

complement-derived anaphylatoxin production. It also directly inhibits leukocyte

adhesion to endothelial cells induced by proinflammatory stimuli, and abolishes

tumor necrosis factor α-induced expression of adhesion molecules on granulocytes

and endothelial cells. Because of these properties it also has anti-inflammatory

activity.39

The efficacy of sodium cromoglycate is dependent on the concentration of the

solution being used; at 1% it has no effect, at 2% it has possible effect and at 4% it

has a probable effect. Lodoxamide is 2500 times more potent than sodium

cromoglycate as far as preventing the release of histamine is concerned.42

The general properties of usage of Mast cell stabilizers for treatment of

allergic eye diseases are as follows:39

Requires long-term usage

They have a slower onset of action

Requires prophylactic dosing

Often does not produce complete disease control when used as standalone

drugs.

Dual action drugs

Olapatadine was the first compound in this class to be approved for use in

allergic conjunctivitis, subsequently other drugs like ketotifen, azelastine and

epinastine have been rolled out. Olapatadine is a benzoxepine which blocks the

histamine H1 receptor as well as prevents the release of proinflammatory mediators

36

from activated human conjunctival mast cells. It prevents the release of mediators like

vasoactive mediators, eicosanoids and cytokines without actually affecting the

integrity of the membranes of mast cells, which is because of the fact that it has low

intrinsic surface activity.43

Though olapatadine can bind with H1, H2, and H3 receptors, its selectivity for

H1 receptors is about 1000 times that for H2 receptors and 4000 times that for H3

receptors. It causes lesser release of lactate dehydrogenase (LDH) from conjunctival

mast cells (which indicates membrane disruption) when compared to ketotifen

fumarate 0.025%, epinastine hydrochloride 0.05% and azelastine hydrochloride

0.05%. This may explain the reason why olapatadine causes less discomfort for

patients after instillation. As far as relieving of symptoms is concerned, olopatadine

hydrochloride 0.1% ophthalmic solution reduces itching as early as 30 minutes after

the instillation. Olapatadine hydrochloride is also available as a 0.2% ophthalmic

solution which can be used as a once-daily regimen, as its effect lasts for 24 hours and

this may improve patient compliance.44

Ketotifen is a potent, selective H1 antihistamine that also prevents mast cell

degranulation. It is structurally analogous to cyproheptadine like antihistamines. It

also inhibits degranulation of eosinophils. It stabilizes the membranes by interacting

with the phospholipid monolayers.45

37

Figure 7 : Structures of dual action agents45

Epinastine is a potent, long acting H1 antihistamine with some activity on H2

receptors also.45

Topical and oral antihistamines

Second generation topical antihistamines like levocabastine hydrochloride

0.05% and emedastine difumarate 0.05% are selective H1 receptor blockers which do

not cross the blood brain barrier and hence have reduced sedative potential, while still

retaining antiallergic effects.46

Oral selective H1 receptor antihistamines can not only

provide an additional benefit along with topical antihistamines, but also are useful for

treating coexisting systemic allergic diseases.47

Non-steroidal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drug (NSAID) topical agents reduce ocular

inflammatory signs by inhibiting cyclooxygenase and have a beneficial effect on the

38

course of VKC reducing the local steroid needs.48

Orally administered NSAIDs like

aspirin and topically administered NSAIDs like flurbiprofen, ketorolac and diclofenac

are known to significantly diminish the ocular itching and conjunctival hyperemia

associated with allergic eye diseases. Another added advantage offered by these drugs

is that unlike steroids they do not mask ocular infections, affect wound healing,

increase IOP or result in cataract formation.49

Flurbiprofen has been found to have a comparable efficacy to betamethasone

on all severities of the disease i.e. mild, moderate and severe, and bulbar lesions were

more amenable to treatment than palpebral lesions.50

Ketorolac tromethamine 0.5% solution is effective in alleviating the prominent

ocular symptoms of itching, discharge, and photophobia of VKC. Amongst the signs,

conjunctival inflammation is reduced significantly but other signs such as papillary

hyperplasia and limbal changes change very little. Ketorolac is more effective in

reducing the prominent ocular symptom of itching compared to placebo.51

Preservative-free diclofenac sodium 0.1% eye drops shows significant

improvement of total signs and symptoms scores in forty per cent of the patients of

VKC, but no significant differences are seen as far as corneal lesions and for papillary

size are concerned.52

A newer mechanism for NSAIDs like aspirin has been found with respect to

its anti-inflammatory property. IL-4, the prototypic cytokine expressed in Th2 cells,

plays a pivotal role in vernal conjunctivitis. Aspirin (acetylsalicylic acid (ASA) shows

direct inhibition of IL-4 production in T cells independent of COX and NF-kB

activity.53

39

Corticosteroids

Corticosteroids (glucocorticoids and mineralocoticoids) are 21 carbon

structures that are synthesized by ACTH controlled conversion of cholesterol in the

adrenal cortex. Those that are produced within the body are called as natural steroids,

which include cortisol, cortisone, corticosterone and aldosterone. The major synthetic

steroids (glucocorticoids) are prednisone, prednisolone, 6-methyl prednisolone,

triamcinolone, 9-fluoro cortisol, paramethasone, betamethasone, dexamethasone, etc.

Two weaker topical corticosteroids namely fluorometholone and medrysone are also

available. Whereas loteprednol and rimexolone are novel ‘soft’ steroids which have

decreased propensity to cause a rise in IOP.

Steroids provide good relief, but carry with them the risk of serious ocular side

effects like raised IOP, propensity for cataractogenesis, etc. Corticosteroids are used

in the treatment of moderate to severe VKC. The features of VKC which prompt the

usage of corticosteroids include persistent severe symptoms, thick mucus discharge

with moderate to severe corneal involvement, numerous and inflamed limbal

infiltrates and/or giant papillae. The appropriate dosage depends on the inflammatory

state of the eye, and treatment is preferably given in pulses of 3–5 days. If steroids

usage becomes inevitable, those with low intraocular absorption, such as

hydrocortisone, clobetasone, desonide, fluorometholone, loteprednol, difluprednate

and rimexolone, should be the preferred choice. Prednisolone, dexamethasone, or

betamethasone should be resorted to only when the above-mentioned first-choice

steroids have proven futile.39

Supratarsal injection of corticosteroids like 2 mg dexamethasone, 10.5 mg

triamcinolone and 50 mg hydrocortisone is found to be effective in improvement of

signs and symptoms of VKC like itching, photophobia, lid oedema, and size of

40

cobblestone papillae, conjunctival chemosis, discharge and Tranta's dots. The corneal

shield ulcers also heal completely by 3 weeks. But after initial rapid clinical

improvement, clinical symptoms and signs tend to recur starting at 12 weeks' follow-

up and the severity of recurrence of disease gradually increases so as to necessitate

repeat injections.54

Whereas recurrence of the disease after supratarsal injection of

triamcinolone acetonide was noted in only 2% of the cases in another study.55

A new class of drugs called as selective glucocorticoid receptor agonists

(SEGRAs) have been studied, which have improved therapeutic index compared to

corticosteroids. An in vitro study on primary human conjunctival epithelial cells

(HConEpiC) and primary human conjunctival fibroblasts (HConF) has observed that

the novel SEGRA mapracorat inhibits allergy-related chemokine/cytokine release and

the expression of ICAM-1. These inhibitory effects were as potent and efficacious as

that of the steroid dexamethasone. SEGRAs, like glucocorticoids, transrepress genes

primarily through tethering type mechanisms and thus have potent anti-inflammatory

activity. But unlike glucocorticoids, SEGRAs are selected to have a decreased ability

to activate gene transcription through binding to simple glucocorticoid responsive

elements, and thus have a lower propensity to induce undesirable side effects.56

Similarly an in vivo study has found that topical mapracorat reduced the composite

score for clinical signs of conjunctivitis (tearing, redness, and edema) as well as the

infiltration of eosinophils into the conjunctiva of guinea pigs with ocular allergy. Also

mapracorat inhibited eosinophil migration and proinflammatory release from

eosinophils and mast cells.57

41

Immunomodulators

Cyclosporine (CsA) is a fungus-derived (Tolypocladium inflatum) cyclic

decapeptide drug. It is a highly lipophilic drug with consequent poor aqueous

solubility of 12 ng/mL. It acts by inhibiting T-cell activation thereby preventing the

release of inflammatory cytokines. It also blocks the opening of mitochondrial

permeability transition pores and inhibits apoptosis. Its usefulness in allergic

inflammation is attributable to its inhibitory effects on eosinophil and mast cell activ

Cyclosporine is a cyclic endecapeptide (molecular mass of 1203 kDa) with N-

methylated amino acids that make the molecule resistant to inactivation by the

gastrointestinal tract and hence usable as an oral immunosuppressive drug (6).

Alternatively, tacrolimus is a macrolide antibiotic (molecular mass of 804 kDa).

Although it is more soluble in water than cyclosporine, it has a similar high solubility

in lipids and other organic solvents (Fig. 1) (1). CNIs bind intracellular proteins called

immunophilins: cyclophilins in the case of cyclosporine A (CsA), and the FKbinding

proteins in the case of tacrolimus (also known as FK506). This complex then binds to

an intracellular molecule called calcineurin, leading to an inhibition of its activity, and

hence inhibiting T cell activation (7). Calcineurin is formed by two subunits: A,

which is a catalytic subunit (CnA) responsible for its phosphatase activity, and B, a

regulatory subunit (CnB) that is particularly responsive to intracellular calcium and

regulates CnA activation (8–11). T cell activation through TCR stimulation elevates

intracellular calcium concentration and activates CnB, which unleashes the

phosphatase activity of CnA. Activated CnA dephosphorylates cytoplasmic NFATc, a

transcription factor, which causes its translocation, along with the activated

calcineurin, into the nucleus where it upregulates the expression of multiple cytokines

and costimulatory molecules necessary for full activation of T cells. Among NFAT

42

family members, NFAT1, NFAT2, and NFAT4 are involved in the trascscriptional

activation of genes encoding cytokines, including IL-2 and IL-4, and CD40 ligand

(12). Production of IL-2, in particular, stimulates the growth and differentiation of T

cells (13). The cyclophilin/CsA and FK-binding protein/FK complexes directly bind

to CnA and inhibit its phosphatase activity. Although inhibiting calcineurin in T cells

was shown to suppress T cell activation, more recent data suggest a negative effect of

CNIs on regulatory T cell proliferation and function (14, 15). Regulatory T cells have

been shown to be essential for immune tolerance induction in transplantation (16).

Whether the use of CNIs will be deleterious to any potential tolerogenic therapeutic

strategy is still unknown.ation and release of mediators.58

Cyclosporine eye drops, either at 1% or 2% concentrations has been found to

be able to significantly improve the ocular objective scores of VKC and did not

produce any significant side effects, even when used for as long as seven years. Hence

is useful as a steroid sparing alternative and thereby obviating the serious side effects

of long term usage of steroids.59

Also oral cyclosporine at dosages of 3 mg/kg body

weight per day is useful in severe refractory and potentially vision-threatening cases

of VKC.60

Tacrolimus is another immune modulator commonly employed as a steroid

sparing drug in the treatment of VKC. It is a 23-member cyclic macrolide lactone and

was originally isolated from Streptomyces tsukubaensisin. It was initially developed

as an immunosuppressant agent for use subsequent to organ transplantation to prevent

rejection. It produces it action by binding to FK506-binding proteins in T

lymphocytes and thereby inhibits calcineurin activity. This inhibition in turn

suppresses dephosphorylation of the nuclear factor of activated T cells and its transfer

into the nucleus, which transforms into decreased formation of T helper 1 (Th1)

43

(interleukin (IL)-2, interferon γ) and Th2 cytokines (IL-4, IL-5). It also has the

capability to inhibit histamine release from mast cells and therefore its ability to

relieve allergic symptoms.61

Though its mechanism of immunomodulation is similar to cyclosporine A but

it is about 100 times more potent than cyclosporine A.62

Various concentrations of

tacrolimus have been used in the treatment of VKC like 0.005%,62

0.03%63

and

0.1%61

. All these dosages have produced alleviation of various signs and symptoms of

VKC. But there is limited data available regarding the optimal duration of treatment

of VKC with tacrolimus.62

Cyclosporine (CsA) is a fungus-derived (Tolypocladium inflatum) cyclic

decapeptide drug. It is a highly lipophilic drug with consequent poor aqueous

solubility of 12 ng/mL. It acts by inhibiting T-cell activation thereby preventing the

release of inflammatory cytokines. It also blocks the opening of mitochondrial

permeability transition pores and inhibits apoptosis. Its usefulness in allergic

inflammation is attributable to its inhibitory effects on eosinophil and mast cell

activation and release of mediators.58

Cyclosporine eye drops, either at 1% or 2% concentrations has been found to

be able to significantly improve the ocular objective scores of VKC and did not

produce any significant side effects, even when used for as long as seven years. Hence

is useful as a steroid sparing alternative and thereby obviating the serious side effects

of long term usage of steroids.59

Also oral cyclosporine at dosages of 3 mg/kg body

weight per day is useful in severe refractory and potentially vision-threatening cases

of VKC.60

44

Surgical management

Surgical intervention may be required under certain circumstances in the

treatment of VKC. These reasons include management of giant papillae and

recalcitrant corneal shield ulcer. Giant papillae may be excised with/without

cryotherapy in the presence of mechanical pseudoptosis or the presence of coarse

giant papillae.64

Excision or cryocoagulation of large papillae also permits early

resolution of corneal epitheliopathy or ulcer, although papillae tend to regrow most

often. Cryotherapy of giant papillae causes inflammation and hence may lead to

conjunctival scarring. Post-operative recurrence of papillae may be reduced by

intraoperative application of 0.02% mitomycin-C (MMC) to the upper palpebral

conjunctiva immediately after papillae resection for 2 min. Giant papillae can also be

removed by CO2 laser. This procedure has the advantage that it can be repeated if

papillae recur.5

Vernal plaque is usually managed by controlling the underlying conjunctival

disease. But in cases were there does not seem to be any spontaneous

epithelialization, then superficial keratectomy with a scleral pocket knife, produces

rapid epithelialization.65

This can be either surgical or excimer laser superficial

keratectomy.66

Amniotic membrane implantation can be used to produce complete re-

epithelialization of persistent corneal epithelial defects and vernal plaques recalcitrant

to conventional medical treatment. Free autologus conjunctival graft also facilitates

the re-epithelializaion of nonhealing shield ulcer after resection of giant papillae.

Cultivated corneal epithelial cells could be transplanted to treat the severe ocular

surface diseases associated with VKC. This is especially useful when amniotic

membrane transplant is not sufficient to restore the ocular surface.5

45

Conjunctival secondary inclusion cysts may develop in chronic VKC. When

there is no change of size of the inclusion cysts, no specific treatment is needed. But

in cases where the size is large, or there is foreign body sensation, corneal

astigmatism, or impediment of sight, excision of the cyst, cryotherapy, electric

cauterization, or YAG laser may be considered.67

Smart steroids

Though corticosteroids are useful in treating various inflammations and

allergic conditions, they are associated with several adverse effects. Topical

administration of corticosteroids for anterior segment inflammatory conditions

maximizes drug delivery to the anterior segment and minimizes systemic exposure. It

also helps avoid systemic adverse drug reactions (ADR) such as hypothalamic-

pituitary-adrenal-(HPA-axis) suppression. Despite this, topical ophthalmic

corticosteroids are associated with local adverse drug reactions like elevations in IOP,

cataract formation following extended use, delayed wound healing, and lower

resistance to infection.68

This is an important stumbling block in the long term use of

corticosteroid for treating various ocular inflammatory conditions.

The processes by which topical corticosteroids increase IOP is unclear. The

glucocorticoid receptor is involved in multiple, diverse signaling pathways, and it is

presumed that steroid induced IOP elevation, especially during long-term use or

where high doses of corticosteroids are used, is the result of upregulation or

repression of one or more genes unrelated to the indication being treated. Trabecular

meshwork (TM) cells and myocilin gene expression are purported to be the cause of

corticosteroid-induced IOP elevation. Corticosteroids appear to decrease the outflow

of aqueous humor by inhibiting the degradation and/or enhancing the deposition of

46

extracellular matrix material within the TM and/or cross-linking of actin fibers

between TM cells.69

The mechanism of steroid-induced cataract is equally imprecise, but the most

prominent hypothesis doing the rounds involves the formation of Schiff bases

between the steroid C 20 ketone group and nucleophilic groups such as ϵ-amino

groups of lysine residues of proteins. Schiff base formation is subsequently followed

by a Heyns rearrangement involving the adjacent C 21 hydroxyl group and affording

stable amine-linked adducts. This covalent binding results in destabilization of the

protein structure allowing further modifications (ie, oxidation) and possibly leading to

cataract.70

Figure 8 : Hypothetical steroid induced cataract mechanism70

Bodor proposed the “soft drug” concept to overcome these difficulties.

Production of a soft drug is achieved by starting with a known inactive and non-toxic

metabolite of an active drug. This inactive metabolite is then modified structurally to

an active albeit metabolically unstable compound that undergoes a predictable one

step transformation to inactive metabolites after producing the desired

pharmacological effects at/near the site of application.71

The inactive metabolite is converted into an isosteric/isoelectronic analogue

with structural modifications designed for rapid, predictable metabolism back to the

47

original inactive metabolite after eliciting the desired therapeutic effect. This is also

called as retrometabolic drug designing.68

Figure 9 : Concept of retrometabolic drug design 68

More than 120 of such soft steroids have been synthesized starting from the

late 1970s.70

Bodor designed a number of analogues, starting with Δ1-cortienic acid,

the primary metabolite of prednisolone, that lacks corticosteroid activity. To obtain

new lead compounds, the pharmacophore moieties of the 17α-hydroxyl and 17β-

carboxy substituents of the lead compound had to be restored by suitable

isosteric/isoelectronic substitution containing esters or other types of functions that

restored the original corticosteroid’s anti-inflammatory potency while incorporating

48

hydrolytic features to ensure metabolism. Other structural considerations included the

presence/absence of double bond at the Δ1 position, fluorination at 6α carbon (X2)

and/or 9α carbon (X1), and methylation at 16α or 16β carbons (R3). Over a hundred

possible drugs were synthesized and tested in preclinical anti-inflammatory models,

and structure/activity studies concluded that the best substitutions for maximal

activity included a haloester at the 17β position and a carbonate or ether at the 17α

position. 17α esters were also considered but were quickly abandoned due to their

potential to form mixed anhydrides with the haloesters, and subsequent potential for

lens protein binding. Thus, in addition to the C-20 ketone moiety of prednisolone

being replaced to avoid the possibility of formation of Schiff base intermediates, other

chemical features associated with potential cataractogenesis were also eliminated by

design.68

The most promising drug candidate among cortienic acid-based derivatives

synthesized was loteprednol etabonate (LE; chloromethyl 17α-ethoxycarbonyloxy-

11β-hydroxy-3-oxoandrosta-1,4-diene, 17β-carboxylate). LE is the 17β-chloromethyl

ester of Δ1-cortienic acid with a 17α-etabonate moiety and was predicted to undergo

rapid deesterification to an inactive carboxylic acid metabolite after exerting its effect,

thereby minimizing the likelihood of toxicity.68

Loteprednol etabonate differs from

other ophthalmic corticosteroids in that it has an ester rather than a ketone at the C-20

position of the core corticosteroid structure.69

49

Figure 10 : Retrometabolic design of cortienic acid based derivatives68

Figure 11 : Structure of Loteprednol etabonate68

50

Loteprednol etabonate when absorbed systemically, is rapidly transformed to

the inactive 17 β-carboxylic acid metabolite and eliminated from the body mainly via

the bile and urine.70

LE is highly lipophilic—its lipophilicity is about 10 times greater than that of

dexamethasone, which allows its enhanced penetration through biological

membranes. Also, competitive binding studies with rat lung type II (Glucocorticoid

receptor) GRs has shown that LE has 4.3 times more binding affinity to these

receptors when compared to dexamethasone. A vasoconstriction test, which is used to

assess bioavailability of a drug, when performed in humans has demonstrated that LE

produced a blanching response similar to that of betamethasone 17α-valerate, hence

has good penetration properties and strong potency. Furthermore the therapeutic index

of LE was found by studies to be more than 20-fold better than that of other

corticosteroids like hydrocortisone 17α-butyrate, betamethasone 17α-valerate, and

clobetasone 17α-proprionate. Ocular absorption and distribution studies in rabbits

using 14 C-labelled LE 0.5% have found that the highest concentrations of LE was

found in the cornea, followed by the iris/ciliary body and aqueous humor. The cornea

also showed the highest ratio of metabolite to LE, indicating that the cornea was the

primary site of metabolism, while aqueous humor concentrations of LE were

approximately 100-fold lower. This may be the reason why LE may exert a decreased

IOP effect comparative to other corticosteroids, as high levels of steroids in the

aqueous humor are thought to contribute to decreased outflow.68

The cornea and conjunctiva are naturally covered with a 3- to 40-lm layer of

mucus. The outer layer is comprised of secreted and other mucins. The inner layer (up

to 500-nm thick) is formed by epithelium tethered mucins (glycocalyx). These form

an important barrier for entry of topically applied drugs. Several studies are underway

51

to find methods to overcome this barrier presented by the mucous layers, one such

method is the development of mucus penetrating nanoparticles (MPP) of various

drugs. This methodology permits diffusion through the mucus and provides an even

distribution of the nanoparticles across the ocular surface. The overall goal of the

loteprednol etabonate mucus-penetrating particles suspension formulation, 0.4% (LE-

MPP 0.4%) is to improve drug penetration into tissues underlying the mucous

barrier.72

The pharmacokinetic profile in the ocular tissues of loteprednol etabonate

ophthalmic suspension using the MPP technology has been studied on New Zealand

White rabbits, wherein it has been found that this formulation of Loteprednol had a

better pharmacokinetic profile than Lotemax 0.5% suspension. Also it had a threefold

higher Cmax (maximum concentration observed) in the aqueous humor, cornea,

iris/ciliary body, and retina, indicating a higher level of absorption in ocular tissues.

This despite the fact that LE-MPP 0.4% contains 20% less active drug than Lotemax

0.5%.72

52

Literature review

(1) Study conducted by Pakid Vichyonond and co authors on 24 VKC patients

enrolled into the study with their mean age 9.61 +/- 2.55years twelve patients

allocated into the Tacrolimus eye ointment and the other twelve into the

cyclosporin eye drops was found Tacrolimus eye ointment and cyclosporin eye

drops were both effective in treatment of VKC.6

(2) Vichyonond and co authors reported marked clinical responses in 10 VKC

patients with Tacrolimus eye ointment.

(3) Study conducted by Nir Erdinest and Abraham Solomon found that topical

Tacrolimus was more effective than Cyclosporin A eye drops as it has the

ability to resolve and manage giant papillae due to VKC hence it is more

effective than Cyclosporin and is more tolerable.7

(4) A study conducted by Sana Illias Tinwala and co authors, found Tacrolimus

has a mechanism of action similar to that of Cyclosporin ,but is 50 to 100

times more porent. The pharmacology of Tacrolimus includes reduction of

proinflammatory cytokines, activated T lymphocytes. It also exerts

neuroprotective effects as well as inhibits the loss of conjunctival

epithelium and decrease in the number of goblet cells.8

(5) A study conducted by Leopoldo M Baiza-Duran et al found Cyclosporin A in

aqueous solution was safe and effective in improving signs and symptoms

of Vernal keratoconjunctivitis patients.Cyclosporin treatment also allowed the

cessation of topical steroid treatment.

53

(6) In this study by rashmi kumari, both topical treatment of 0.03% FK-506

ophthalmic ointment and 0.05% cyclosporine eye drops caused significant

decrease in TSSS from 4th weeks onwards examined the efficacy of tacrolimus

compared to cyclosporine.

(7) A similar prospective, double-masked, randomized comparative study was

conducted by Labcharoenwongs et. al.12 in which twenty-four VKC patients

received 0.1% tacrolimus eye ointment twicedaily for 8 weeks, and the other 24

received 2% cyclosporine A eye drops for the same duration. This study reported

that tacrolimus treatment brought about an improvement of the signs and

symptoms of VKC similar to that of cyclosporine A treatment. In addition, this

study concluded that cyclosporine A treatment was related to a burning sensation

and pain on application, compared with a transient burning sensation which was

detected in patients with tacrolimus treatment. Objective ocular signs were found

to be more improved with tacrolimus treatment, even though this was not

statistically significant. Our study didn’t show any significant difference between

the efficacy of the two drugs .At the same time there was no ocular side effects in

either group. More over the beneficial effect of tacrolimus on signs especially on

papillary size as mentioned in the above study and many other studies as well was

not present in our study. This difference can be attributed to the lower

concentration of drugs(0.03%) as compared to 0.1% used in most of the other

study.

(8) A study by shamir s shougy and et al a Low-dose topical tacrolimus 0.01%

solution is effective and safe in the management of patients with refractory VKC.

1. Kumar S. Vernal keratoconjunctivitis: a major review. Acta Ophthalmol.

2009;87(2):133–147.

54

METHODOLOGY

This study titled “A COMPARITIVE STUDY OF EFFICACY,

TOLERABILITY, SAFETY OF 0.03% TACROLIMUS EYE OINTMENT AND

0.05%CYCLOSPORIN EYE DROPS IN THE TREATMENT OF VERNAL

KERATOCONJUNCTIVITIS was carried out in the Department of Ophthalmology,

KR Hospital, Mysore during the period of January 2017 to January 2018 after

obtaining the ethical clearance.

Source of Data

Patients of VKC attending the department of Ophthalmology, K.R Hospital, Mysore.

METHODS OF COLLECTION OF DATA

STUDY DESIGN: Comparative study

SAMPLE SIZE: 72

SAMPLING METHOD: purposive sampling

INCLUSION CRITERIA

(1) Patients of 5 years or older with a clinical diagnosis of VKC

EXCLUSION CRITERIA

(1) Patients who had other ocular disorders like Glaucoma, infectious keratitis,and

posterior segment abnormalities.

(2) Patients with one blind eye

(3) Contact lens users.

55

METHOD OF STUDY

Data was collected from patients after informed consent.

A complete general physical & ophthalmologic examination including

visual acuity determination(snellen chart &near vision chart) ,slit lamp examination

(zeiss), Intraocular measurement(I CARE) & fundus examination(Indirect

ophthalmoscope) were conducted.

patients were requested to discontinue all the ophthalmologic and oral anti

allergic drugs with the exception of preservative free artificial tears for 2 weeks

run in period .

After 2 week run in period in 1ST

visit complete ophthalmologic

examination was done as above & grading for ocular symptoms ( itching,

watering & photophobia) and signs (palpebral hyperaemia ,bulbar hyperemia, &

papillae ) were done.

Patients were alloted into 2 groups I & II.

Group I was requested to use 0.03%tacrolimus eye ointment twice daily

& Group I1 was requested to use 0.05%cyclosporin eye drops 4 times daily.

A complete ophthalmologic assessment was done again at 15 days ,

1month, 3 months,6months.

During follow up visit all patients were evaluated for improvement in

subjective symptoms , objective signs ,& ocular safety.

Ocular safety was assessed based on changes in visual acuity, Intra ocular

pressure & fundus examination.

56

Subjective and objective assessments of the signs and symptoms of vernal

keratoconjunctivitis were done using standard scoring methodologies.

Scoring was done for the signs (papillae, bulbar hyperemia and palpebral

hyperemia) and symptoms (itching, photophobia and tearing) of VKC using standard

scoring methodologies as follows:

Signs scoring

PAPPILAE 82

Grade 0 Absent

Grade 1 A few papillae of less than 0.2 mm

Grade 2 Papillae of 0.3 to 1 mm on the tarsal conjunctiva

Grade 3 Papillae of 1 to 3 mm throughout the tarsal conjunctival area

HYPEREMIA (BULBAR CONJUNCTIVA)83

Grade 0 None

Grade 1 Mild (dilation of a few blood vessels)

Grade 2 Moderate (dilation of many blood vessels)

Grade 3 Severe (dilation of all blood vessels, Eyes look congested)

HYPEREMIA (PALPEBRAL CONJUNCTIVA)83

Grade 0 None

Grade 1 Mild (dilation of a few blood vessels in part of palpebral conjunctiva)

Grade 2 Moderate (dilation of many blood vessels in entire palpebral conjunctiva)

Grade 3 Severe (redness of entire palpebral conjunctiva; individual blood vessels

cannot be distinguished)

57

Symptoms scoring

ITCHING84

Grade 0 No itching

Grade 1 Occasional sensation of itching

Grade 2 Frequent sensation but occasional rubbing

Grade 3 Sensation of rubbing is almost always and frequent rubbing any time of

the day

PHOTOPHOBIA84

Grade 0 None

Grade 1 Outdoors only

Grade 2 Indoors-bright light (TV, computer…)

Grade 3 Indoors, prefers darkened room

watering83

Grade 0 None

Grade 1 Mild (eye feels slightly watery)

Grade 2 Moderate (blows nose occasionally)

Grade 3 Severe (tears overflow)

Patient’s clinical responses (i.e. signs and symptoms scoring) and tolerability

(IOP measurements) to the treatment was determined at presentation and 14 (week 2),

28 (week 4), 90 (week 12) and 180(week 24) days post treatment, through

appropriate follow-up visits.

58

STATISTICAL METHODS USED

Data was analyzed using SPSS (Statistical Presentation System Software) for

windows (version 20.0). The statistical methods adopted for the study were as

follows:

Descriptive statistics

Inferential statistics (crosstab procedure) and Cramer’s V

59

ESTIMATION OF SAMPLE SIZE

Sample size: seventy two patients.

Based on the prevalence of 4%, using the formula S=Z2pq/d

2 with Z value of

1.96 and proportion of prevalence as 0.04 and margin of error as 0.05 the estimated

sample size is 60.

60

RESULTS

The following are the results of the study entitled “A COMPARITIVE STUDY OF

EFFICACY, TOLERABILITY, SAFETY OF 0.03% TACROLIMUS EYE

OINTMENT AND 0.05%CYCLOSPORIN EYE DROPS IN THE TREATMENT

OF VERNAL KERATOCONJUNCTIVITIS that was carried out in the Department

of Ophthalmology, KR Hospital, Mysore.

Age distribution of VKC cases:

The distribution of VKC cases in different age groups and the descriptive statistics

pertaining to age in these cases are presented in Table 1, Table 2 & Chart 1.

Table 1; Age distribution of VKC cases

groups Total

Group I Group II

ages 5-9 Count 20 13 33

% within groups 55.6% 36.1% 45.8%

10-14 Count 12 21 33

% within groups 33.3% 58.3% 45.8%

15+ Count 4 2 6

% within groups 11.1% 5.6% 8.3%

Total Count 36 36 72

% within groups 100.0% 100.0% 100.0%

61

Table 2: Symmetric Measures

Value Approx. Sig.

Nominal by Nominal Phi .253 .100

Cramer's V .253 .100

N of Valid Cases 72

.

b. Using the asymptotic standard error assuming the nul hypote

Chart 1: Distribution of age in VKC cases

0

5

10

15

20

25

5--9 y 10--14 y 15+ y

Fre

qu

en

cy

Age

Group I Group II

The majority of VKC cases were seen in the 5-9 years group (51%), closely

followed by the 10-14 years group (39%). The above 15 years group constituted 10%

of the VKC cases.

62

The youngest patient in our study was 5 years old, while the oldest was 25

years old.

Gender wise distribution of VKC cases:

The gender wise distribution of VKC cases are presented in Table 3 & Chart 2

Table 3: Genderwise distribution of VKC cases

groups Total

Group I Group II

sex Male Count 30 32 62

% within groups 83.3% 88.9% 86.1%

Female Count 6 4 10

% within groups 16.7% 11.1% 13.9%

Total Count 36 36 72

% within groups 100.0% 100.0% 100.0%

Table 4: Symmetric Measures

Value Approx. Sig.

Nominal by Nominal Phi -.080 .496

Cramer's V .080 .496

N of Valid Cases 72

a. Not assuming the null hypothesis.

b. Using the asymptotic standard error assuming the null hypothesis.

63

Chart 2: Gender wise distribution of VKC cases

T-Test

Group Statistics

groups N Mean Std. Deviation Std. Error Mean

age Group I 36 9.81 4.091 .682

Group II 36 10.50 2.249 .375

Independent Samples Test

t-test for Equality of Means

t df Sig. (2-

tailed)

Mean

Difference

Std. Error

Difference

age -.893 70 .375 -.694 .778

64

In the study group (72 patients) 86% were males and females constituted 14%.

The ratio of M:F was 9:1. This picture is also seen in both the individual treatment

groups.

Itching:

The changes in the itching scores during the treatment period for the

cyclosporin and tacrolimus group are provided in Table 5 ,while the results of

statistical analysis for the two groups vis-a-vis the effect of treatment on itching

scores is presented in Table 6. Chart 3 graphically shows the mean itching scores as

was present in the two groups at various intervals of time.

Table 5: Itching scores in both the treatment groups during treatment period

Groups itching Total

G 0 G 1 G 2 G 3

Group

I

visit Initial Count 0 12 21 3 36

% within visit 0.0% 33.3% 58.3% 8.3% 100.0%

First Count 9 17 9 1 36

% within visit 25.0% 47.2% 25.0% 2.8% 100.0%

Second Count 21 14 1 0 36

% within visit 58.3% 38.9% 2.8% 0.0% 100.0%

Third Count 34 2 0 0 36

% within visit 94.4% 5.6% 0.0% 0.0% 100.0%

Fourth Count 35 0 0 0 35

% within visit 100.0% 0.0% 0.0% 0.0% 100.0%

Total Count 99 45 31 4 179

% within visit 55.3% 25.1% 17.3% 2.2% 100.0%

Group

II

visit Initial Count 0 2 34 36

% within visit 0.0% 5.6% 94.4% 100.0%

First Count 0 25 11 36

% within visit 0.0% 69.4% 30.6% 100.0%

Second Count 19 17 0 36

% within visit 52.8% 47.2% 0.0% 100.0%

Third Count 35 1 0 36

% within visit 97.2% 2.8% 0.0% 100.0%

Fourth Count 36 0 0 36

% within visit 100.0% 0.0% 0.0% 100.0%

Total Count 90 45 45 180

65

% within visit 50.0% 25.0% 25.0% 100.0%

Total visit Initial Count 0 14 55 3 72

% within visit 0.0% 19.4% 76.4% 4.2% 100.0%

First Count 9 42 20 1 72

% within visit 12.5% 58.3% 27.8% 1.4% 100.0%

Second Count 40 31 1 0 72

% within visit 55.6% 43.1% 1.4% 0.0% 100.0%

Third Count 69 3 0 0 72

% within visit 95.8% 4.2% 0.0% 0.0% 100.0%

Fourth Count 71 0 0 0 71

% within visit 100.0% 0.0% 0.0% 0.0% 100.0%

Total Count 189 90 76 4 359

% within visit 52.6% 25.1% 21.2% 1.1% 100.0%

Table 6:Chi-Square Tests

groups Value df Asymp. Sig. (2-sided)

Group I Pearson Chi-Square 134.819 12 .000

Group II Pearson Chi-Square 224.111 8 .000

Total Pearson Chi-Square 345.372 12 .000

66

Chart 3: itching scores in both the groups

0

5

10

15

20

25

30

35

40

Initial First Second Third Fourth Initial First Second Third Fourth

Group I Group II

0

9

21

34 35

0 0

19

35 36

12

17

14

2 0

2

25

17

1 0

21

9

1 0 0

34

11

0 0 03 1 0 0 0 0 0 0 0 0

Fre

qu

en

cy o

f it

chin

g

Group

G 3 G 2 G 1 G 0

The itching scores in both the treatment groups improved over the 24week

observation period. .

Photophobia:

The changes in the photophobia scores during the treatment period for

cyclosporin and tacrolimus group are provided in Table 7 while the results of

statistical analysis for the two groups vis-a-vis the effect of treatment on photophobia

scores is presented in Table 8. Chart 4 graphically shows the mean photophobia

scores as was present in the two groups at various intervals of time.

67

Table 7: Photophobia changes in both the groups during treatment period

groups photophobia Total

G 0 G 1 G 2 G 3

Group

I

visit Initial Count 0 14 21 1 36

% within visit 0.0% 38.9% 58.3% 2.8% 100.0%

First Count 0 23 13 0 36

% within visit 0.0% 63.9% 36.1% 0.0% 100.0%

Second Count 21 14 1 0 36

% within visit 58.3% 38.9% 2.8% 0.0% 100.0%

Third Count 34 1 1 0 36

% within visit 94.4% 2.8% 2.8% 0.0% 100.0%

Fourth Count 34 1 0 0 35

% within visit 97.1% 2.9% 0.0% 0.0% 100.0%

Total Count 89 53 36 1 179

% within visit 49.7% 29.6% 20.1% 0.6% 100.0%

Group

II

visit Initial Count 0 13 23 36

% within visit 0.0% 36.1% 63.9% 100.0%

First Count 0 23 13 36

% within visit 0.0% 63.9% 36.1% 100.0%

Second Count 8 27 1 36

% within visit 22.2% 75.0% 2.8% 100.0%

Third Count 29 6 1 36

% within visit 80.6% 16.7% 2.8% 100.0%

Fourth Count 34 2 0 36

% within visit 94.4% 5.6% 0.0% 100.0%

Total Count 71 71 38 180

% within visit 39.4% 39.4% 21.1% 100.0%

Total visit Initial Count 0 27 44 1 72

% within visit 0.0% 37.5% 61.1% 1.4% 100.0%

First Count 0 46 26 0 72

% within visit 0.0% 63.9% 36.1% 0.0% 100.0%

Second Count 29 41 2 0 72

% within visit 40.3% 56.9% 2.8% 0.0% 100.0%

Third Count 63 7 2 0 72

% within visit 87.5% 9.7% 2.8% 0.0% 100.0%

Fourth Count 68 3 0 0 71

% within visit 95.8% 4.2% 0.0% 0.0% 100.0%

Total Count 160 124 74 1 359

% within visit 44.6% 34.5% 20.6% 0.3% 100.0%

68

Table 8:Chi-Square Tests

Groups Value df Asymp. Sig. (2-sided)

Group I Pearson Chi-Square 152.743 12 .000

Group II Pearson Chi-Square 160.556 8 .000

Total Pearson Chi-Square 302.875 12 .000

Chart 4: Photobhobia changes in both the groups during treatment

0

5

10

15

20

25

30

35

40

Initial First Second Third Fourth Initial First Second Third Fourth

Group I Group II

0 0

21

34 34

0 0

8

2934

14

23

14

1 1

13

23

27

6

2

21

13

1 1 0

23

13

1 1 01 0 0 0 0 0 0 0 0 0

Fre

qu

en

cy o

f re

dn

ess

Group

G 3 G 2 G 1 G 0

The photophobia scores in both the treatment groups improved over the

24week observation period. .

Watering:

The changes in watering scores during the treatment period for the cyclosporin

and Tacrolimus group are provided in Table 9 while the results of statistical analysis

for the two groups vis-a-vis the effect of treatment on watering scores is presented in

69

Table 10. Chart 5 graphically shows the mean watering scores as was present in the

two groups at various intervals of time.

Table 9: Watering scores in both the groups during treatment period

groups watering Total

G 0 G 1 G 2 G 3

Group

I

visit Initial Count 6 10 19 1 36

% within visit 16.7% 27.8% 52.8% 2.8% 100.0%

First Count 7 18 11 0 36

% within visit 19.4% 50.0% 30.6% 0.0% 100.0%

Second Count 29 7 0 0 36

% within visit 80.6% 19.4% 0.0% 0.0% 100.0%

Third Count 36 0 0 0 36

% within visit 100.0% 0.0% 0.0% 0.0% 100.0%

Fourth Count 36 0 0 0 36

% within visit 100.0% 0.0% 0.0% 0.0% 100.0%

Total Count 113 35 30 1 179

% within visit 63.1% 19.6% 16.8% 0.6% 100.0%

Group

II

visit Initial Count 8 23 5 36

% within visit 22.2% 63.9% 13.9% 100.0%

First Count 11 24 1 36

% within visit 30.6% 66.7% 2.8% 100.0%

Second Count 23 13 0 36

% within visit 63.9% 36.1% 0.0% 100.0%

Third Count 36 0 0 36

% within visit 100.0% 0.0% 0.0% 100.0%

Fourth Count 36 0 0 36

% within visit 100.0% 0.0% 0.0% 100.0%

Total Count 114 60 6 180

% within visit 63.3% 33.3% 3.3% 100.0%

Total visit Initial Count 14 33 24 1 72

% within visit 19.4% 45.8% 33.3% 1.4% 100.0%

First Count 18 42 12 0 72

% within visit 25.0% 58.3% 16.7% 0.0% 100.0%

Second Count 52 20 0 0 72

% within visit 72.2% 27.8% 0.0% 0.0% 100.0%

Third Count 72 0 0 0 72

% within visit 100.0% 0.0% 0.0% 0.0% 100.0%

Fourth Count 71 0 0 0 71

% within visit 100.0% 0.0% 0.0% 0.0% 100.0%

Total Count 227 95 36 1 359

% within visit 63.2% 26.5% 10.0% 0.3% 100.0%

70

Chart 5:Watering changes in both the groups during treatment period

Table 10: Chi-Square Tests

groups Value df Asymp. Sig. (2-sided)

Group I Pearson Chi-Square 126.270 12 .000

Group II Pearson Chi-Square 92.833 8 .000

Total Pearson Chi-Square 213.413 12 .000

The watering scores in both the treatment groups improved over the 8 week

observation period. .

Bulbar hyperemia:

The changes in the bulbar hyperemia scores during the treatment period for the

cyclosporin and tacrolimus group are provided in Table 11,while the results of

statistical analysis for the two groups vis-a-vis the effect of treatment on bulbar

71

hyperemia scores is presented in Table 12. Chart 6 graphically shows the mean bulbar

hyperemia scores as was present in the two groups at various intervals of time.

Table 11: Bulbar hyperemia changes in both the groups during treatment period

groups bulbarhyperemia Total

G 0 G 1 G 2 G 3

Group

I

visit Initial Count 0 13 22 1 36

% within visit 0.0% 36.1% 61.1% 2.8% 100.0%

First Count 0 30 6 0 36

% within visit 0.0% 83.3% 16.7% 0.0% 100.0%

Second Count 21 15 0 0 36

% within visit 58.3% 41.7% 0.0% 0.0% 100.0%

Third Count 34 2 0 0 36

% within visit 94.4% 5.6% 0.0% 0.0% 100.0%

Fourth Count 34 1 0 0 35

% within visit 97.1% 2.9% 0.0% 0.0% 100.0%

Total Count 89 61 28 1 179

% within visit 49.7% 34.1% 15.6% 0.6% 100.0%

Group

II

visit Initial Count 0 11 25 36

% within visit 0.0% 30.6% 69.4% 100.0%

First Count 0 32 4 36

% within visit 0.0% 88.9% 11.1% 100.0%

Second Count 9 26 1 36

% within visit 25.0% 72.2% 2.8% 100.0%

Third Count 30 6 0 36

% within visit 83.3% 16.7% 0.0% 100.0%

Fourth Count 34 2 0 36

% within visit 94.4% 5.6% 0.0% 100.0%

Total Count 73 77 30 180

% within visit 40.6% 42.8% 16.7% 100.0%

Total visit Initial Count 0 24 47 1 72

% within visit 0.0% 33.3% 65.3% 1.4% 100.0%

First Count 0 62 10 0 72

% within visit 0.0% 86.1% 13.9% 0.0% 100.0%

Second Count 30 41 1 0 72

% within visit 41.7% 56.9% 1.4% 0.0% 100.0%

Third Count 64 8 0 0 72

% within visit 88.9% 11.1% 0.0% 0.0% 100.0%

Fourth Count 68 3 0 0 71

% within visit 95.8% 4.2% 0.0% 0.0% 100.0%

Total Count 162 138 58 1 359

% within visit 45.1% 38.4% 16.2% 0.3% 100.0%

72

Table 12:Chi-Square Tests

groups Value df Asymp. Sig. (2-sided)

Group I Pearson Chi-Square 179.849 12 .000

Group II Pearson Chi-Square 194.214 8 .000

Total Pearson Chi-Square 365.743 12 .000

Chart 6:Bulbar hyperemia changes during treatment period in both the groups

The bulbar hyperemia scores in both the treatment groups improved over the

24 week observation period. .

Palpebral hyperemia:

The changes in the palpebral hyperemia scores during the treatment period for

the cyclosporin and tacrolimus group are provided in Table 13 while the results of

statistical analysis for the two groups vis-a-vis the effect of treatment on palpebral

73

hyperemia scores is presented in Table 14. Chart 7 graphically shows the mean

palpebral hyperemia scores as was present in the two groups at various intervals of

time.

Table 13: Palpebral hyperemia scores in both the groups during treatment period

groups Palpebralhyperemia Total

G 0 G 1 G 2 G 3

Group I visit Initial Count 0 13 21 2 36

% within visit 0.0% 36.1% 58.3% 5.6% 100.0%

First Count 0 34 2 0 36

% within visit 0.0% 94.4% 5.6% 0.0% 100.0%

Second Count 15 20 1 0 36

% within visit 41.7% 55.6% 2.8% 0.0% 100.0%

Third Count 34 1 1 0 36

% within visit 94.4% 2.8% 2.8% 0.0% 100.0%

Fourth Count 34 1 0 0 35

% within visit 97.1% 2.9% 0.0% 0.0% 100.0%

Total Count 83 69 25 2 179

% within visit 46.4% 38.5% 14.0% 1.1% 100.0%

Group II visit Initial Count 0 13 23 36

% within visit 0.0% 36.1% 63.9% 100.0%

First Count 0 33 3 36

% within visit 0.0% 91.7% 8.3% 100.0%

Second Count 15 20 1 36

% within visit 41.7% 55.6% 2.8% 100.0%

Third Count 34 2 0 36

% within visit 94.4% 5.6% 0.0% 100.0%

Fourth Count 36 0 0 36

% within visit 100.0% 0.0% 0.0% 100.0%

Total Count 85 68 27 180

% within visit 47.2% 37.8% 15.0% 100.0%

Total visit Initial Count 0 26 44 2 72

% within visit 0.0% 36.1% 61.1% 2.8% 100.0%

First Count 0 67 5 0 72

% within visit 0.0% 93.1% 6.9% 0.0% 100.0%

Second Count 30 40 2 0 72

% within visit 41.7% 55.6% 2.8% 0.0% 100.0%

Third Count 68 3 1 0 72

% within visit 94.4% 4.2% 1.4% 0.0% 100.0%

Fourth Count 70 1 0 0 71

% within visit 98.6% 1.4% 0.0% 0.0% 100.0%

Total Count 168 137 52 2 359

% within visit 46.8% 38.2% 14.5% 0.6% 100.0%

74

Table 14:Chi-Square Tests

groups Value df Asymp. Sig. (2-

sided)

Group I Pearson Chi-Square 198.260 12 .000

Group II Pearson Chi-Square 199.491 8 .000

Total Pearson Chi-Square 397.487 12 .000

Chart 7: Palpebral hyperemia scores in both the groups during treatment period

The palpebral hyperemia scores in both the treatment groups improved over

the 24 week observation period. .

Papillae:

The changes in the papillae scores during the treatment period for cyclosporin

and tacrolimus group are provided in Table 20 and Table 21 respectively. While the

results of statistical analysis for the two groups vis-a-vis the effect of treatment on

75

papillae scores is presented in Table 22. Chart 9 graphically shows the mean papillae

scores as was present in the two groups at various intervals of time.

Table 15 : Papillae scores in both the groups during treatment period

groups papillae Total

G 0 G 1 G 2

Group I visit Initial Count 0 12 24 36

% within visit 0.0% 33.3% 66.7% 100.0%

First Count 0 30 6 36

% within visit 0.0% 83.3% 16.7% 100.0%

Second Count 1 31 4 36

% within visit 2.8% 86.1% 11.1% 100.0%

Third Count 12 23 1 36

% within visit 33.3% 63.9% 2.8% 100.0%

Fourth Count 34 1 0 35

% within visit 97.1% 2.9% 0.0% 100.0%

Total Count 47 97 35 179

% within visit 26.3% 54.2% 19.6% 100.0%

Group

II

visit Initial Count 0 18 18 36

% within visit 0.0% 50.0% 50.0% 100.0%

First Count 0 22 14 36

% within visit 0.0% 61.1% 38.9% 100.0%

Second Count 14 22 0 36

% within visit 38.9% 61.1% 0.0% 100.0%

Third Count 27 9 0 36

% within visit 75.0% 25.0% 0.0% 100.0%

Fourth Count 36 0 0 36

% within visit 100.0% 0.0% 0.0% 100.0%

Total Count 77 71 32 180

% within visit 42.8% 39.4% 17.8% 100.0%

Total visit Initial Count 0 30 42 72

% within visit 0.0% 41.7% 58.3% 100.0%

First Count 0 52 20 72

% within visit 0.0% 72.2% 27.8% 100.0%

Second Count 15 53 4 72

% within visit 20.8% 73.6% 5.6% 100.0%

Third Count 39 32 1 72

% within visit 54.2% 44.4% 1.4% 100.0%

Fourth Count 70 1 0 71

% within visit 98.6% 1.4% 0.0% 100.0%

Total Count 124 168 67 359

% within visit 34.5% 46.8% 18.7% 100.0%

76

Table 16 :Chi-Square Tests

groups Value df Asymp. Sig. (2-sided)

Group I Pearson Chi-Square 181.433 8 .000

Group II Pearson Chi-Square 142.161 8 .000

Total Pearson Chi-Square 294.078 8 .000

Chart 8: Papillae scores in both the groups during treatment period

The papillae scores in both the treatment groups improved over the 24 week

observation period. .

77

DISCUSSION

In this study the majority of VKC cases were seen in the 5-15 years group ,

(86%). 14% of the VKC cases were above 15 years of age.The youngest patient in

this study was 5 years old, while the oldest was 25 years old. This study findings as

far as the age of occurrence and distribution of VKC cases in different age groups is

in concordance with such studies done in other parts of the world.

In a case series of 406 vernal keratoconjunctivitis patients studied by Leonardi

A et al in Padua, Italy found that at the time of diagnosis, 83% of patients were under

10 years of age, with the average age of onset in males and females being 7.0 + 5 and

7.5 + 6 years respectively. When patients were divided into smaller age subgroups,

the highest prevalence of VKC was found in the 6–10 years group (56.3%).85

In a study by Al-Akily SA and Bamashmus MA done in Yemen the majority

of cases with VKC examined in this study were younger than 10 years. (49.2%). The

highest number of cases were found in the 5–9 years group (180 cases, 41.76%),

followed by the 10–14 years group (144 cases, 33.41%).86

VKC is commoner in males, with the male to female ratio in different studies

varying from 4:1 to 2:1.5

In this study group (72 patients) 80% were males and

females constituted 20%. The ratio of M:F was 4:1. This picture is also seen in both

the individual treatment groups. In the Yemeni study the majority of VKC patients

(n= 431) were males (n= 327) and females (n= 104) with a male:female ratio of

3.1:1.86

In the Italian study the vast majority of VKC patients (n = 311) were male

(76%), with a male:female ratio of 3.3:1.

78

In this study the baseline characteristics were similar between the

groups.0.05% cyclosporine eye drops resulted in an approximately 97% reduction in

symptoms and signs of VKC by the end of 24 weeks of treatment ,as there were no

similar studies of same duration and concentration of drug available for

comparison,the response of 35% reduction in symptoms and signs at 2 weeks has

been compared with a similar study done by pucci et al in a double masked trial

where in 2% cyclosporine resulted in an approximately 40% reduction in symptoms

and signs which was in concordance.

However in this study because of low concentration of 0.05% of cyclosporine

only 3% of patients reported burning sensation and was better tolerated hence were

able to use throught out the study period which has resulted in better resolution 97%

compared to other studies with cyclosporine eye drops preparation of various

concentration (0.1%, 1%, 2% by pucci et al, sunilkumar et al, Labcharoenwongs et

al,2012) where in () of patients have discontinued the drugs resulting in recurrence of

disease. .

In a longer open trial by Spadavecchi et al,2006, utilizing a lower

concentration of cyclosporine (1.25% and 1%) for 4 months, a higher degree of

benefit in subjective and objective scores were reported which is in concordance with

the present study.

At all points of treatment IOP, lens and fundus remained with in normal limits.

Difference in efficacy of cyclosporine in various publications by

Spadavecchi et al (cyclosporine (1.25% and 1%) for 4 months, by De Smedt et

al,2012 of cyclosporine of 2%.could be due to difference in concentration of

cyclosporine eye drops and duration of treatment. cyclosporine eye drops caused

79

significant decrease in symptoms and signs from 2ndweek onwards which was similar

to prospective, double-masked, randomized comparative study conducted by

Labcharoenwongs et al,2012, in which twenty-four VKC patients received 0.1%

tacrolimus eye ointment twice-daily for 8 weeks, and the other 24 received

cyclosporine A 2% eye drops for the same duration study period .

0.03% Tacrolimus eye ointment resulted remission in 100% of Patients in

VKC by the end of 24 weeks of treatment which is in concordance with the study

done by Abdulrahman et al in which after 6 weeks of 0.1% tacrolimus eye ointment

all the patients were asymptomatic with least adverse effects.

In this study 7% of patients reported mild irritation which was tolerated by the

patients hence were able to continue the drug for full study period resulting in 100%

remission of the VKC, which is in concordance with the study done by sunil et in

7.4% of patients reported mild irritation with good tolerance, none of the patients

discontinued the drug.

In this study also all the patients have received treatment for throught out the

study period because of lower concentration with negligible adverse effects resulting

ingood response.

Patients on treatment with 0.03% Tacrolimus eye ointment did not require any

additional medications, which showed its potential role as steroid sparing agent which

is in concordance with the study done by sunilkumar etal by Atsuki kshmy et al in

which 53.4% of patients using steroids were successfully weaned from topical

steroids, having steroids replacing effect.

At all points of treatment IOP, lens and fundus remained with in normal limits.

80

In this study both the drugs 0.05% cyclosporine eye drops and 0.03%

Tacrolimus eye ointment were almost equally efficacious (97% and 100%

respectively) in treating VKC which is in concordance with a similar prospective

double masked , randomized comparative study done by Rashmi kumar et al in 2016

in which 0.03% Tacrolimus eye ointment brought about an improvement of the signs

and symptoms of VKC similar to cyclosporine eye drops.

This study did not show any significant difference between the efficacy of

drugs.

At the same time there were no ocular side effects in either group which is in

agreement with the study done by Ekta singla et al.

Also IOP lens and fundus of all the patients were with in normal limits at all

pointa of treatment in either group which is in concordance with study done by

Rashmikumar et al, Eksingla et al.

In a study by Rashmi kumar et al signs were found to be more improved with

0.03% Tacrolimus eye ointment even though this was statistically not significant.

This study results are in concordance with a prospective double masked,

randomized comparative study conducted in 2016 by Kumari R and Saha CB.[16]In

which 19 patients received 0.03% tacrolimus eye ointment daily for 6 weeks and other

15 received 0.5% cyclosporine eye drops four times daily for 6 weeks. This study

reported that tacrolimus brought about an improvement of the signs and symptoms of

VKC similar to that of cyclosporine A.

81

CONCLUSION

Both 0.05% cyclosporine eye drops and 0.03% Tacrolimus eye ointment were

1. Equally efficacious in treatment of VKC(97% and 100% respectively)

2. Tolerability in either group were good with negligible side effects like irritation

and burning sensation.

3. There was no evidence of increase IOP , cataract.

This proved to be safer alternative for steroids.

So in conclusion both the drugs were able to successfully resolve the

symptoms and signs of VKC,were tolerable with no significant adverse effects and

much safer alternative to steroids as it caused no elevation of intraocular pressure and

steroid related complications.

82

SUMMARY

This study entitled “A comparative study of the efficacy of topical

cyclosporine 0.05% eye drops and Tacrolimus eye ointment 0.03% in the treatment

of vernal keratoconjunctivitis” was envisaged to compare the effectiveness of these

drugs in relieving the symptoms of VKC and also to observe their effects on the IOP.

72 patients of VKC each who satisfied the inclusion and exclusion criteria were

allotted into the two treatment groups (i.e. Group I and group I1) by non-random

purposive sampling.

The patients of VKC at presentation were subjected to complete ocular

examination including slit lamp examination, visual acuity assessment with Snellen’s

chart, intraocular pressure measurement and other relevant investigations were done.

Subjective and objective assessments of the signs and symptoms of vernal

keratoconjunctivitis was done using standard scoring methodologies. Scoring was

done for the symptoms (itching, photophobia and tearing) and signs (papillae, bulbar

hyperemia and palpebral hyperemia) of VKC.

Patient’s clinical responses (i.e. signs and symptoms scoring) and tolerability

(IOP measurements) to the treatment was determined at presentation and 14 (week 2),

28 (week 4), 42 (week 6) and 180 days (week 24) post treatment, through appropriate

follow-up visits.

Data that was obtained were analyzed using SPSS (Statistical Presentation

System Software) for windows (version 20.0). The statistical methods adopted for the

study were as follows: Descriptive statistics, Inferential statistics (crosstab

procedure)/Cramer’s V and Independent-Samples ‘t’ test.

83

The majority of VKC cases were seen in the 5-9 years group (49%), closely

followed by the 10-14 years group (37%),5-14 years constituted about 86% and 15-25

years constituted about 14%. In the study group (72 patients) 90% were males and

females constituted 10%. The ratio of M:F was 9:1.

The baseline IOP i.e. before initiation of treatment was 13.98 + 2.86 (mm of

Hg) and 14.14 + 2.79 (mm of Hg) in the cyclosporine 0.05% eye drops and

Tacrolimus0.03% eye ointment groups respectively. And there was no statistically

significant difference (t = -0.283, p = > 0.05) as far as the IOP between the two

groups at the time of initial presentation. During the follow-up period after initiation

of treatment, the IOP values at all points of time were with in normal limits.

As far as the signs and symptoms are concerned both the drugs i.e.

cyclosporine 0.05% eye drops and and Tacrolimus0.03% eye ointment were able to

control the signs and symptoms of VKC over the 6 month period of observation.

These drugs were especially good at resolving the symptoms of VKC (itching,

photophobia and watering) completely over this particular period and were also able

to act on the signs (bulbar/palpebral hyperemia and papillae) to a large extent. So in

conclusion both the drugs0.05% cyclosporine eye drops and 0.03%Tacrolimus eye

ointment were able to successfully resolve the signs and symptoms of VKC.

84

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100

CONSENT FORM

I have been explained in complete detail in my own language regarding the

study entitled “A comparative study of the efficacy of topical loteprednol etabonate

0.5% ophthalmic solution and fluorometholone 0.1% in the treatment of vernal

keratoconjunctivitis” . I have had the opportunity to ask questions about it and any

questions that I have asked have been answered to my satisfaction. I consent

voluntarily to participate/allow my ward to participate as a participant in this study.

Name of Participant__________________

Signature of Participant/Parent/Guardian _______________

Date ___________________________

Day/month/year

Name of Researcher/person taking the consent________________________

Signature of Researcher /person taking the consent__________________________

Date ___________________________

Day/month/year

96

PROFORMA FOR COLLECTION OF DATA

Title of the topic – “A comparative study of the efficacy of topical loteprednol

etabonate 0.5% and fluorometholone 0.1% in the treatment of vernal

keratoconjunctivitis”

Name:

Age:

Sex:

Address:

Occupation:

Chief complaints

Vernal Keratoconjunctivitis history

Time since onset:

Seasonal variations, if any:

Previous medications, if any:

Family history of VKC:

Family history of other allergies:

97

General physical examination

Pallor/icterus/cyanosis/lymphadenopathy/edema

Pulse:

BP:

Cardiovascular system: Normal/Abnormal (If abnormal specify –

Respiratory system: Normal/Abnormal (If abnormal specify –

Nervous system: Normal/Abnormal (If abnormal specify -

Ocular examination

Head posture:

Ocular posture:

Extraocular movements:

Right -

Left -

Visual acuity:

Right eye Left eye

Eyelid

Conjunctiva

Palpebral

Bulbar

Sclera

Cornea

Anterior chamber

98

Treatment prescribed – loteprednol etabonate 0.5% / fluorometholone 0.1%

Symptom scoring

Itching Initial visit Week 2 Week 4 Week 6 Week 8

Right eye

Left eye

Photophobia Initial visit Week 2 Week 4 Week 6 Week 8

Right eye

Left eye

Tearing Initial visit Week 2 Week 4 Week 6 Week 8

Right eye

Left eye

Signs scoring

Bulbar

hyperemia

Initial visit Week 2 Week 4 Week 6 Week 8

Right eye

Left eye

Iris

Pupil

Lens

IOP

Fundus

99

Palpebral

hyperemia

Initial visit Week 2 Week 4 Week 6 Week 8

Right eye

Left eye

Papillae Initial visit Week 2 Week 4 Week 6 Week 8

Right eye

Left eye

Intraocular pressure

Intraocular

pressure

(mm of Hg)

Initial visit Week 2 Week 4 Week 6 Week 8

Right eye

Left eye

101

PHOTOS

Figure 12 : I care tonometer

Figure 13 : Measurement of IOP

102

Figure 14 : Bulbar hyperemia

Figure 15 : Palpebral hyperemia

103

Figure 16 : Papillae