Dr. Cremers Protocol for Vernal keratoconjunctivitis (VKC)

Vernal keratoconjunctivitis (VKC) is a severe form of allergic conjunctivitis that primarily affects children and young adults, often worsening in the spring and summer. I have seen adults in their 30’s though, with sever VKC. VKC can affect one’s vision and even lead to sterile corneal ulcers so VKC should be treated aggressively depending on symptoms. As with any condition, you ever have eye pain, see you MD/OD asap  

Treatment options for VKC aim to control symptoms, reduce inflammation, and prevent complications. The best treatment options:

1. Allergen Avoidance and Environmental Control: 

- Reducing exposure to known allergens can help manage VKC symptoms. This includes keeping windows closed during high pollen seasons and using air filters 

2.  Lubricating Eye Drops: 

- Artificial tears can help alleviate dryness and discomfort associated with VKC. Preservative-free formulations are preferred to avoid further irritation. 

3. Cold Compresses: 

- Applying cold compresses to the eyes can provide symptomatic relief from itching and swelling. 

1. Topical Antihistamines and Mast Cell Stabilizers: Finding preservative free versions of the below can be difficult. Most of them are over-the-counter if you cannot find a preservative free version try the preservative version, but stop it if it irritates the eye.

-Antihistamines: These provide rapid relief from itching and other allergic symptoms. Examples include olopatadine and ketotifen: these are over-the-counter and I usually used once twice a day

- Mast Cell Stabilizers: These help prevent the release of inflammatory mediators. Examples include cromolyn sodium and nedocromil: these are often over-the-counter and are used once or twice a day

5. Topical Cyclosporine

- Cyclosporine A is an immunomodulatory agent that can reduce inflammation and is beneficial for long-term management of VKC. It is often used when symptoms are not controlled with antihistamines and mast cell stabilizers 

Verkazia® (cyclosporine ophthalmic emulsion) 0.1% is a calcineurin inhibitor immunosuppressant indicated for the treatment of vernal keratoconjunctivitis: use 1 drops, 4 x per day. 

Patients should use Verkazia at least 10 minutes before using other eye drops and wait at least 15 minutes post-instillation before reinserting contact lenses. 

Other FDA-approved cyclosporine eye drops, used 1 drop twice a day: 

Restasis Cyclosporine A 0.05%; Cequa Cyclosporine A 0.09%; Vevye: Cyclosporine A 0.1%); Ikervis (Cyclosporine A 1 mg/mL) available in Europe. 

6. Topical Corticosteroids

For severe inflammation, short-term use of topical corticosteroids such as prednisolone or loteprednol can be effective. Long-term use is generally avoided due to potential side effects like increased intraocular pressure and cataract formation. Patients can be allergic to preservative so if you have a negative reaction, let your doctor know. 

7. Topical Tacrolimus:

- Tacrolimus is another immunosuppressant that has shown efficacy in treating VKC. It can be used in cases resistant to other treatments: 0.03% or 0.1% tacrolimus ophthalmic ointment is often prescribed off-label: applied to the lower conjunctival sac. - Initial Dose: Apply a small amount (about 1 cm) of the ointment to the affected eye(s) twice daily. - Maintenance Dose: Once symptoms are under control, the frequency may be reduced to once daily or even less frequently as needed.

1. Patient Instructions:

- Application: use clean hands and place drop in eye and/or ointment in the lower conjunctival sac without contaminating the tube or bottle tip. Use alcohol wipe if tip touches anything. 

- Hygiene: Always wash hands before and after application to prevent infection.

- If you use Contact Lenses: remove contact lenses before applying the ointment and wait at least 15 minutes before reinserting them.

5. Monitoring and Follow-Up:

-Follow-Up: within a few weeks to months depending on improvement. If symptoms subside follow up in 1 year. 

6. Side Effects and Precautions:

- Common Side Effects: Include burning, stinging, or itching at the application site. These usually diminish over time. Serious Side Effects: Rare but may include increased risk of infections. 

1. Oral Antihistamines: 

- For systemic relief, oral antihistamines such as loratadine or cetirizine can be used, particularly if there are associated allergic symptoms like rhinitis but these can dry out tear film & make dryness worse. 

9. Surgical Interventions: 

- In rare and severe cases, surgical interventions may be necessary to address complications such as corneal ulcers or shield ulcers. 

Different individuals prefer some options/drops over others. Keep track of which drops make you feel worse. CONTACT an allergist to help  in the management plan.

For further details, you can refer to sources like:

- [AAO's Guide on Vernal Keratoconjunctivitis](https://www.aao.org/eye-health/diseases/vernal-keratoconjunctivitis-list)