spring catarrah

1. SPRING CATARRAH BY: YOHANANTH SIVANANTHAN ROLL NO:132 NEPALGUNJ MEDICAL COLLEGE NEPAL AUG 10 BATCH OPTHALMOLOGY SEMINAR SERIES

2. 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.

3. 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.

4. 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

5. pathogenesis

6. 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…

7. 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.

8. SIGNS Signs may be described under 3 clinical forms of disease Palperbral form Bulbar form Mixed form

9. 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

10. 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.

11. 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.

12. MIXED FORM It shows combined features of both palperbral and bulbar form

13. 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

14. 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.

15. CLINICAL COURSE SELF LIMITING USUALLY BURNS OUT SPONTANEOUSLY AFTER 5 TO 10 YEARS.

16. 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.

17. 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.

18. 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.

19. Systemic therapy Oral antihistamininics Anti allergic Relive from itching Oral steroids Short duration recommended for advanced,very severe non responsive cases.

20. 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. Prophylaxis beta radiation,disodium chromoglycate 2% 3 to 4 times.