SPRING CATARRAH

BY: YOHANANTH SIVANANTHANROLL NO:132

NEPALGUNJ MEDICAL COLLEGENEPAL

AUG 10 BATCHOPTHALMOLOGY SEMINAR SERIES

VERNAL KERATOCONJUNCTIVITIS[SPRING CATARRH]

It is a recurrent, bilateral, interstitial, self limiting allergic inflammation of the conjunctiva may have a periodic seasonal incidence.

It is a type of allergic conjunctivitis. Occuring with the onset of hotweather,

during summer rather than spring. Sporadic and non contagious in nature. Recently it also called as warm weather

conjunctivitis.

INCIDENCE Sporadically occur in wide geographical

incidence. More common in indian subcontinent and

africa like tropical countries than europe. Coloured races are more prone to form

limbal form of disease. Essentially disease of youth occuring more

frequently in between ages of 5-10 years. Sex incidence very high pecentages are

seen in males Family history of allergy found in 40-60

percentages.

ETIOLOGY Three theories are found currently

Due to the action of physical factors like Heat Humidity Light

Due to the endocrine glands and vagotonic states Manifestation of an allegic condition.

Pollens Toxins Dusts Animal debris,hair Inhalants Injestants

Mostly pathogenesis IgE mediated allegic reaction

PATHOGENESIS

PATHOLOGY Conjunctval epithelium

Undergoes hyperplasia Sends downwards projections into the sub epithelial

tissue Adenoid layer

Marked cellular infiltrations Eosinophils, plasmacells, lymphocytes,and histiocytes

Fibrous layer Shows proliferation Later on undergoes hyaline changes

Conjunctival vessels Proliferation Increased permeability and vasodilation. All these lead to formation of multiple papillae in the

upper tarsal conjunctiva…

SYMPTOMS Marked burning and foreignbody sensation. Itching sensation. Mild photophobia. Lacrimation+watering Stringy( thick ropy white) discharge and

heaviness of lids.

in the cooler months the conditions subsides and symptoms persits and is symptomsless although the lesions persists,but recur with the return of the heat.

SIGNS Signs may be described under 3 clinical

forms of disease

Palperbral form

Bulbar form

Mixed form

PALPERBRAL FORM Usually upper tarsal conjunctiva of

both eyes involved. Easily recognised On everting upper lid the palperbral

conjunctiva is seen to be hypertropied and mapped out into polygonal raised are like cobblestones or pavement stones fashion.

In severe cases papillae may hypertropy-produce giant papillae,cauliflower like excresenses.

The colour is bluish white,like milk,and this apppearancce may also be seen over the lower palperbral conjunctiva.

The flat topped nodules are hard consist cheifly of dense fibrous tissue,but the epithelium over them thickned giving rise to milky hue.

Histologically they are hypertrophied papillae not follicles

Eosinophillic leukocytes are present in them in great numbers and found in the secretion

Infiltrationof lymphocytes,plasmacells,macrophages,basophills.

Palperbral form cannot be mistaked if typical but may resemble trachoma.

LIMBAL OR BULBAR FORM Recognised by an

opacification of the limbus with nodules or a wall of gelatinous thickening at the limbus

Dusky red triangular conjestion of bulbar conjunctiva in palperbral area.

White dots consisting the esonophills and epithelial debris known as horner-trantas dots if seen at limbus are a very characteristic feature.

MIXED FORM It shows combined features of both

palperbral and bulbar form

COMPLICATIONS Mainly due to corneal involvement

otherwise prognosis is good

Vernal keratopathy Due to corneal involvement in vernal

kerato conjunctivitis May be primary or secondary due to

extension of limbal lesions. Includes 5 types of lesions

PUNCTATE EPITHELIAL KERATITIS INVOLVE UPPER CORNEA MOSTLY WITH PALPERBRAL FORM STAIN WITH ROSEBENGAL INVARIABLY WITH

FLOURESCEIN ULCERATIVE VERNAL KERATITIS

SHALLOW TRANSVERSE ULCER IN UPPER CORNEA VERNAL CORNEAL PLAQUES

DUE TO COATING OF BARE AREAS OF EPITHELIAL MACRO EROSIONS WITH A LAYER OF ALTERED EXUDATES

SUBEPITHELIAL SCARRING IN A FORM OF RING SCAR

PSEUDOGERONTOXON. CHARACTERISED BY CUPID BOW OUTLINE.

CLINICAL COURSE SELF LIMITING USUALLY BURNS OUT SPONTANEOUSLY

AFTER 5 TO 10 YEARS.

DIFFERENTIAL DIAGNOSIS TRACHOMA

Mainly trachoma with predominant papillary hypertrophy from palperbralform of spring catarrah

It can be differentiated as follows

Papillae are large and usually cobblestone appearance in spring catarrah.

Ph of tears alkaline in spring catarrah while in trachoma acidic.

Discharge ropy in spring catarrah

Conjunctival cytology and labtest in difficult cases.

TREATMENT Local therapy

Topical steroids. Used for all type of spring

catarrah Beware of steroid induced

glucoma in prolonged use Measure IOP during

treatment Frequent instillation 4 houly

for 2days, then 3-4times a day for 2 weeks

Fluorometholone medrysone.

Betamethosone. Dextramethosone Medrysone and

flurometholone are most safest.

Local theraphy Mast cell stabilizers.

Sodium chromoglycate 2% drops 4-5 times a day

Topical antihistaminics. Acetyl cysteine 0.5%

Mucolytic properties In early plaque formation

Topical cyclosporine 1% In un responsible cases Steroid resistant cases.

Systemic therapyOral antihistamininics

Anti allergic Relive from itching

Oral steroids Short duration recommended for advanced,very

severe non responsive cases.

Treatment for large papillae. Giant papillae can be tackled by

Supratarsal injection of long acting steroids. Cryo application Sugical excision recommended for extra ordinary large papillae

General measures Dark goggles for photophobia Coldcompression for soothing effect Change of place to hot to cold area if possible

Desensitization Treatment for vernal keratopathy

Punctate epithilial type-no extra treatment instillation of steroid must be increased.

Large vernal plaque-surgery(superficial keratectomy) Severe shied ulcer-resistant to medical theraphy

Sugery is preffered in debridement,superficial keratectomy,eximer laser,therapeutic keratectomy.

Prophylaxisbeta radiation,disodium chromoglycate 2% 3 to 4 times.