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OCULAR FEATURES OFVERNAL KERATOCONJUNCTIVITIS
IN CHILDRENREQUIRING TRABECULECTOMY WITHMITOMYCIN-C FOR STEROID-INDUCED
GLAUCOMACORDELIA CHAN FRCSEd
MARCUS ANG MMedDONALD TAN FRCOphth
FINANCIAL DISCLOSURES CORDELIA CHAN
Consultant, Carl Zeiss Meditec (Travel Sponsorship) MARCUS ANG
Nil DONALD TAN
Patents / Royalty, NetWork Medical Products
The authors have no financial interest in the subject matter of this poster
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VERNALKERATOCONJUNCTIVITIS
Vernal keratoconjunctivitis (VKC) isa severe form of ocular allergy thataffects mostly children and youngadults, with a prevalence of up to 5-15% amongst children
The disease is often chronic andpersistent in the tropical climates in
Asia, unlike the seasonalexacerbations seen in temperateclimates
The chronic forms in Asians eyesmay be at high risk of permanentvisual impairment from cornealscarring, cataract formation andglaucoma secondary tocorticosteroid therapy
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STEROID RESPONSE IN VKC Steroid response inVKC can lead to a
secondary open-angleglaucoma, which maypersist even after corticosteroid therapy isdiscontinued and the IOPnormalizes
Patients with VKCreceiving corticosteroidtherapy have beenreported to be associatedwith a 2-7% incidence of
glaucoma
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PURPOSE We analysed cases of severe VKC with
corticosteroid-induced glaucoma in our Asianpopulation, and describe from these cases theclinical profile of patients requiringtrabeculectomy with mitomycin-C (MMC).
The risk factors for trabeculectomy as well asthe disease patterns and intraocular pressure
control following surgery are highlighted
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MATERIALS AND METHODS A retrospective case-controlled review of medical records of all cases
of VKC seen in a single Center from 1 Jan 03 to 31 Dec 08. Data wasentered into standardized data collection forms designed specificallyfor the study
The disease severity was graded based on the definition by Bonini etal. Clinical grade 3 and 4 (severe and very severe) were included
in the study Bonini S, Sacchetti M, Mantelli F, Lambiase A. Clinical grading of vernal
keratoconjunctivitis. Curr Opin Allergy Clin Immunol 2007 Oct;7(5):436-41.
Corticosteroid-induced glaucoma was diagnosed if eyes had morethan two recordings of increased IOP > 21mmHg on Goldmannapplanation tonometry, and glaucomatous optic nerve head changesor glaucomatous visual field defects on Humphrey 24-2 full thresholdtesting
The clinical profile of steroid responders with failed medical therapyrequiring trabeculectomy with MMC ( 0.02%, applied for 3-5min ), andtheir outcomes following surgery were documented.
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RESULTS A total of 171 patients with severe VKC were reviewed, of
which 36 patients (21.0%) were found to have corticosteroid-
induced glaucoma 6 patients (8 eyes) (16.7%) of these steroid responders
underwent trabeculectomy with MMC after failed medicaltherapy
SUMMARY PROFILE OF PATIENTS REQUIRINGTRABECULECTOMY WITH MMC Mean age: 9.3 years (+/-4.5) Sex: All male Mean maximum IOP: 38.8mmHg (+/-7.9) Mean increase in IOP from baseline: 29.0mmHg (+/-8.2) All had severe topical steroid dependent disease. 1 patient was
given a short-course of oral steroids All required two or more IOP lowering eyedrops pre-operatively
Mean duration of disease at time of trabeculectomy: 7.2 years
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PATIENTS REQUIRING TRABECULECTOMY WITH MMC
Patient (Age/Sex /Race)
Systemicatopic
diseaseand /or
familyhistory of
atopy
Durationof disease
(years)
at time of surgery
No. of Recurren
ces PeakIOP
(mmHg)
Durationof
steroid
use (Weeks)
Mainsteroid
used
No. of anti-glaucoma
medications Type of Surgery
MeanClinicalgrade of
VKC
Pre-operative
MeanClinicalgrade of
VKC
Post-operative
P-value
4/M/c Y 4 3 35 9 D 2
RTrabeculectomy
/ MMC
L: 3.934 R: 4.000
L: 1.000 R: 0.932
0.014
5/M/i Y 3
12 31 18 D 3 R & L
Trabeculectomy/ MMC
L: 3.666 R: 4.000
L: 1.000 R: 1.022
0.035
7/M/i Y 4 3 42 7 D 2
LTrabeculectomy
/ MMC
L: 4.000 R: 0.534
L: 1.000 R: 0.534
0.001
7/M/c Y 6 6 34 72 D 3 R
Trabeculectomy/ MMC
L: 3.332 R: 3.668
L: 3.668 R: 0.932
0.001
13/M/c Y 9 10 53 30 D 2 R & L
Trabeculectomy/ MMC
L: 3.668 R: 3.934
L: 0.934 R: 0.934
0.030
14/M/c Y 6 8 38 39 PF 2 L
Trabeculectomy/ MMC
L: 3.268 R: 3.934
L: 0.866 R: 3.868 0.001
Demographics: Age= Presenting Age, M=Male, c= Chinese, i=Indian, m=Malay; Medical history: Y=Yes, N=No; Mainsteroid used: D=Dexamethasone 0.1% Topical, PF= Predforte 1.0% Topical; Clinical grade of VKC: Based on modifiedclinical grading by Bonini et al 8 weeks pre-operatively and duration of post-operative period.
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RISK FACTORS FOR TRABECULECTOMY VKC patients with steroid response requiring
trabeculectomy with MMC were compared with thosetreated medically
This was performed with age and gender-adjustedlogistic regression
Risk factors : Longer duration of steroid use (OR 1.1; 95%CI, 1.0-1.3;
p=0.035) Higher peak IOP (OR1.3; 95%CI, 1.0-1.5; p=0.017)
Greater increase in IOP from baseline (OR 1.3; 95%CI, 1.0-1.5;p=0.011)
Multivariate analysis revealed this to be the most significant risk factor
Other factors eg type of steroid used, type of VKC (ie limbal,tarsal, mixed), corneal involvement or neovascularization were
not found to be significant
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POST-TRABECULECTOMY OUTCOMES
Significant improvement in severity of VKC post-trabeculectomy in all 8 eyes,with reduced dependence on topicalsteroids
Mean clinical grade of improvement 2.1;95% CI, 1.3-3.0; p
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DISCUSSION The risk of corticosteroid-induced glaucoma in Asianeyes with VKC may be higher due to the chronicity of the
disease and the long-term use of topical steroids, as inthe patients in our study
Our study found important risk factors for trabeculectomyin these cases to be longer duration of topical steroiduse, higher peak IOP and greater increase in IOP frombaseline
The limitations of our study are its small numbers andretrospective nature
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DISCUSSION Mitomycin C is an antibiotic-anticancer agent that inhibits
DNA, RNA and protein synthesis and has a long-term effecton cell proliferation. It induces prolonged localised inhibition of Tenons fibroblasts, thus reducing trabeculectomy blebscarring. Its usefulness when applied topically in VKC hasbeen described
In our study, following trabeculectomy with MMC, all eyes sawsignificant improvement in the ocular surface requiringminimal or no use of topical steroids for control of VKCsymptoms
We postulate that the application of 0.02% MMC directly tothe bare sclera in the superior fornix during trabeculectomyinduces significant long-term inhibition of fibroblast andinflammatory cells in the ocular surface, resulting in animprovement in the signs and symptoms of VKC in our
patients
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CONCLUSIONS Prolonged duration of topical steroid use and
greater increase in IOP from baseline are significantrisk factors for severe steroid response requiringtrabeculectomy in Asian patients with severe formsof VKC
Significant improvement in the signs and symptomsof VKC is seen in eyes following trabeculectomywith MMC . This could be related to the after-effectsof MMC on the ocular surface. This supports the
usefulness of MMC in the management of severe,refractory forms of VKC
A Presentation bythe
Singapo re National Eye Center Singapo re National Eye Centre