Introduction
Vernal keratoconjunctivitis (VKC) is a bilateral, chronic, sight-threatening and severe inflammatory ocular disease mainly occurring in children. The commonage of onset is before 10 years (4–7 years of age).1 It is characterized by chronic, bilateral, recurrent, interstitial, self-limiting allergic inflammation of conjunctiva having a periodic seasonal incidence.2, 3, 4 The disease is more common among males, with the male to female ratio varying from 4:1 to 2:1. It is characterized by itching, redness, discomfort, stringy discharge, photophobia, burning and stinging, giant papillae on the upper tarsal conjunctiva, superficial keratopathy, and corneal shield ulcers, keratoconus leading on to permanent corneal damage. 5 VKC has been included in the newest classification of ocular surface hypersensitivity disorders as both an IgE- and non-IgE mediated ocular allergic disease.6 Additionally, not well defined, non-specific hypersensitivity responses could be implicated in the pathophysiology of the disease. The etiology of VKC may involve a variety of factors, such as genetic predispositions, environmental allergens, and climate changes. Th2 mediated mechanism with an over-expression of cytokines, growth factors; eosinophils and eosinophilic proteins7 is the main immunopathogenesis involved in the disease etiology. Ptosis as a complication of VKC has not been studied much and the aim of this study was to establish a relation between acquired ptosis in young adults and chronic VKC.
The main cause of ptosis in VKC is levator disinsertion that is similar to involutional ptosis. Chronic inflammation of the upper eyelid with giantpapillary conjunctivitis and persistent rubbing of the eyelids may be responsible for the development of this pathology.
To see the relation between long-standing vernal keratoconjunctivitis (VKC) and acquired ptosis in young adults.
Materials and Methods
We conducted a hospital based non-comparative, observational study, in the Department of Ophthalmology, SKIMS Medical College Hospital, Srinagar from March 2020 to May 22. 60 patients upto the age of 40 years with any form of VKC were included in the study. Patients suffering from other ocular infections and ocular trauma and patients using contact lenses were excluded from the study. Predesigned study proforma was used to collect data and history was obtained with special attention to characteristic symptoms and duration of occurrence of symptoms.
Results
Mean age of cases was 16.23± 6.97. Out of 60 patients maximum were in the age group of 10-15 years (31.66%), followed by the age group of 15-20 years (21.66%). Out of total 60 cases 46 were male and 14 were female as shown in Table 2. Palpebral form of the disease was seen to be in most of the cases 53.33%, followed by mixed form of the disease in 28.33% and bulbar disease in 18.33% of the cases as shown in Table 1.
Table 1
Age distribution and clinical type of VKC
Presence of acquired ptosis as a complication due to VKC was seen in 9(15%) patients. Out of these 9 patients 7 patients presented with unilateral ptosis and 2 patients presented with bilateral ptosis. Average duration of symptoms in these patients was 5.0±1.8 years (Table 3), indicating that ptosis is a complication of long-standing VKC. All these patients had palpebral or mixed form of VKC, none had bulbar form of the disease.
Discussion
Vernal keratoconjunctivitis can jeopardize the quality of life, and school performance of affected children and hence their future potential.8, 9 In our study mean age of cases was 16.23± 6.97. Out of 60 patients maximum were in the age group of 10-15 years (31.66%), followed by the age group of 15-20 years (21.66%).
Out of total 60 cases 46(76.66%) were male and 14(23.33) were female. Similar observations were made by most authors. Palpebral form of the disease was seen to be in most of the cases 53.33%, followed by mixed form of the disease in 28.33% and bulbar disease in 18.33% of the cases.
Acquired ptosis as a complication due to VKC was seen in 9(15%) patients. Out of these 9 patients 7 patients presented with unilateral ptosis and 2 patients presented with bilateral ptosis. Average duration of symptoms in these patients was 5.0±1.8 years. Bonini et al., in their study reported mechanical ptosis in 5.1% of cases.9, 8 A study conducted by Dr. Surekha Banga et al10 found mechanical ptosis as a complication of VKC in 11% of the cases.
In our study all the patients had palpebral or mixed form of VKC, none had bulbar form of the disease.
Conclusion
Our study revealed that prolonged severe VKC may induce a lower position of the upper eyelid and eventually lead to ptosis. This could be due to the heavy giant papillae, chronic eye rubbing, or an inflammatory insult to the levator palpebrae superioris muscle and its subsequentdis-insertion. Ptosis is a non-reversible complication of VKC and requires surgical correction. Thus better primary eye care for the management of VKC in children may prevent this complication.
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