This patient-education article is written by the cornea service at Suraj Eye Institute, Nagpur.

What is Vernal Keratoconjunctivitis?

Vernal keratoconjunctivitis (VKC) is a severe, chronic allergic disease of the conjunctiva and the cornea that affects children and adolescents — most often boys between the ages of 4 and 15. It is more common and more severe in hot, dry climates and in children with a personal or family history of allergy, asthma or eczema. Although the disease often improves after puberty, untreated VKC can cause corneal scarring, vision loss and a markedly increased lifetime risk of keratoconus from chronic eye-rubbing.

Vernal Keratoconjunctivitis — Palpebral and Limbal Forms

VKC — Palpebral and Limbal Forms

PALPEBRAL VKC Everted upper lid — cobblestone papillae

Cobblestone (giant) papillae

LIMBAL VKC Horner-Trantas dots at the limbus

Horner-Trantas dots (eosinophil collections)

Figure 1. VKC has two main patterns. Palpebral VKC (left) shows giant cobblestone papillae on the everted upper tarsal conjunctiva. Limbal VKC (right) shows gelatinous thickening of the limbus with characteristic small chalky white nodules — Horner-Trantas dots — that represent collections of eosinophils. Many children have a mixed pattern.

Symptoms

The dominant symptom is intense itching, often described as the worst feature of the disease. Children rub the eyes vigorously and may not be able to attend school during severe flares. Other symptoms include thick, ropy mucus discharge, intense photophobia, watering and redness. Symptoms classically worsen in summer (hence the name vernal) but in tropical climates many children have year-round disease.

Complications

The serious complications of VKC are corneal:

  • Shield ulcer — a sterile oval corneal ulcer in the upper cornea caused by chronic abrasion from the cobblestone papillae
  • Limbal stem cell damage from chronic limbal inflammation
  • Keratoconus — the link with VKC is well established; chronic vigorous eye-rubbing is the most important preventable risk factor. We screen for keratoconus with Anterion corneal topography in children who have severe VKC and are old enough to cooperate with the scan (usually from about 8–10 years of age), which takes only a few seconds

How VKC is Diagnosed

Diagnosis is clinical. The combination of severe itching, ropy discharge, cobblestone papillae on lid eversion and / or Horner-Trantas dots at the limbus is virtually diagnostic. Symptom severity, photophobia and corneal involvement are graded at every visit. Where keratoconus is suspected we perform corneal topography.

Treatment

Treatment is stepped. Long-term steroid-sparing control is the goal:

  • Allergen avoidance and education — cool compresses, sunglasses outdoors, frequent face washing, the do not rub instruction repeated at every visit
  • Topical mast-cell stabilisers and antihistamines (olopatadine, ketotifen) as a year-round baseline
  • Topical cyclosporine 0.1 % or tacrolimus 0.03 % for steroid-sparing long-term control in moderate to severe disease
  • Short pulses of topical steroid for acute flares only, with close intraocular pressure monitoring
  • Shield ulcer management — superficial keratectomy with amniotic membrane patch in severe non-healing cases
Steroids are essential but risky in children. Topical corticosteroids work, but children are especially susceptible to steroid-induced glaucoma and cataract. Steroid use is therefore strictly limited to short pulses for flares, always under specialist supervision, with intraocular pressure checks.
✔ VKC Care at Suraj Eye Institute

VKC is common in our paediatric population. We offer structured grading at every visit, prescribe topical cyclosporine and tacrolimus for steroid-sparing long-term control, monitor intraocular pressure carefully when steroids are necessary, and screen affected children for early keratoconus — for which habitual eye-rubbing is the chief preventable risk factor.

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Frequently Asked Questions

Will my child grow out of VKC?
Most children improve substantially after puberty and many become symptom-free. A minority continue with a milder adult form (atopic keratoconjunctivitis). The aim of childhood treatment is to control symptoms and prevent permanent corneal damage during the years of active disease.

Why is rubbing the eyes so dangerous in VKC?
Chronic vigorous eye-rubbing damages the cornea mechanically, can break down the surface (shield ulcer) and is the most important known risk factor for keratoconus — a separate, lifelong condition that can permanently reduce vision. Stopping the rubbing is the single most important behavioural change.

Are steroid drops safe to use?
Topical steroids are very effective at controlling VKC flares but in children they carry a real risk of steroid-induced glaucoma and cataract. We use them in short, monitored pulses only, and we transition to steroid-sparing drops (cyclosporine, tacrolimus) for long-term control.

Are antihistamine tablets enough?
Oral antihistamines help the itching but rarely control VKC alone, because much of the inflammation is at the eye surface and on the lid itself. Topical mast-cell stabilisers and immunomodulators reach the local tissue effectively.

How often should my child be checked?
Children with moderate-to-severe VKC are typically reviewed every two to three months while symptoms are active, more often during flares. Corneal topography is added once or twice a year in older children to detect early keratoconus.

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