A Challenging Journey Through The Management Of Keratoconus With Keratoconjunctivitis In A Pediatric Population

Vernal keratoconjunctivitis (VKC) is a severe allergic inflammatory disease affecting both cornea and conjunctiva in children and young adults.

Keratoconus is an ectatic corneal disease characterized by progressive stromal thinning, irregular astigmatism, with a potential for significant visual deterioration,  and is one of the most common corneal complications of VKC.

This case study aims to describe an association of these two diseases, with focus on the natural history and treatment strategies of KC associated with VKC. Patients with VKC should be carefully monitored for the development of KC: tight control of local inflammation and prompt awareness with consequent restrain of eye rubbing.

This case study aims to describe the case of 5 children received in the pediatric Ophthalmology department, the age is between 6 yo and 10 yo.

The medical history was relevant for a long-term history of itching, photophobia, white mucous discharge, foreign body sensation, and pain due to corneal involvement of shield ulcers. 

All patients were evaluated by means of a Scheimpflug camera combined with a Placido corneal topographer demonstrated topographic signs of KC. 3 of them were bilateral

On clinical examination, we found a reduced vision : the mean BCVA was 20/400,meibomian gland dysfunction, severe  inflammation,  

Vernal keratoconjunctivitis in all the patients:Giant papillary conjunctivitis:  giant papillae of the upper tarsal conjunctiva, giving the classic 'cobble-stone' appearance.

Corneal plaques and ulcers, from the effect of eosinophilic granular proteins on corneal epithelium and by physical trauma by intense eye rubbing, 

The topography revealed central steepening with inferior-superior dioptric asymmetry. According to the clinical findings, all the patient were diagnosed with keratoconus.

The management  included collagen cross-linking for all the patients, and intrastromal corneal ring segment implantation for 2 patients. 

Steroids were used for their high effect in controlling both an acute episode; because of their long-term complications, Immunomodulators : tacrolimus and cyclosporine were used as steroid-sparing agents, associated to artificial tears, and treatment of ocular allergy, was tolerated by most patients without significant side effects. 

Surgery was required for the management of shield ulcer with inflammatory plaque:  we realised surgical debridement with an amniotic membrane transplantation.

Appropriate management of inflammation in the perioperative period is crucial for achieving successful outcomes. 3 months after the treatment, the mean BCVA  successfully improved for all the patients. 

KC is a common complication of VKC, It is more severe and progresses faster in the setting of VKC, with remarkable visual deterioration and with an increased need for keratoplasty.

Early detection of both VKC and KC enables effective management of KC progression, control of its underlying mechanisms, and helps preserve the vision and quality of life for young patients

An annual evaluation of these patients with corneal topography and/or tomography is essential for early detection of keratoconus and its timely management that includes collagen cross-linking and intrastromal corneal ring segment implantation.