A 9-year-old boy from Delhi presents with intense itching and foreign body sensation in both eyes for the past 3 months, worse in spring and summer. On examination, he has bilateral conjunctival injection, mucoid discharge, and prominent papillae on the upper tarsal conjunctiva. His visual acuity is 6/9 in both eyes. Slit-lamp examination shows no corneal involvement at present. What is the most appropriate initial management?

Explanation

## Diagnosis: Vernal Keratoconjunctivitis (VKC) ### Clinical Features Consistent with VKC **Key Point:** VKC is a chronic, bilateral allergic inflammation of the conjunctiva and cornea, predominantly affecting children and adolescents in warm climates. The clinical presentation in this case is classic: - Age: 9 years (peak incidence 4–25 years) - Seasonality: worse in spring/summer - Bilateral involvement - Intense itching and foreign body sensation - Mucoid discharge - **Giant papillae on upper tarsal conjunctiva** (pathognomonic finding) - No corneal scarring yet (early stage) ### Management Strategy **High-Yield:** VKC management follows a stepwise approach based on severity and presence of corneal involvement. | Stage | Clinical Features | Management | |-------|-------------------|-------------| | **Mild** | Itching, papillae, no corneal involvement | Mast cell stabilizers, cold compresses, lubricants | | **Moderate** | Persistent symptoms despite mild therapy | Add topical antihistamines or weak topical steroids | | **Severe** | Corneal involvement (shield ulcer, keratoconus) | Potent topical steroids, cycloplegics, consider immunosuppressants | **Clinical Pearl:** Mast cell stabilizers (sodium cromoglycate 4%, lodoxamide) are the first-line agents because they: 1. Prevent mast cell degranulation 2. Reduce histamine release 3. Have minimal side effects with long-term use 4. Address the underlying allergic pathophysiology **Tip:** Cold compresses provide immediate symptomatic relief by causing vasoconstriction and reducing itching. ### Why Initial Steroids Are NOT Recommended **Warning:** Topical corticosteroids should be reserved for: - Acute exacerbations with significant inflammation - Corneal involvement (shield ulcer, keratoconus) - Failure of first-line therapy Early use of steroids risks: - Steroid-induced glaucoma - Posterior subcapsular cataract formation - Masking of disease progression - Rebound inflammation upon withdrawal Since this patient has no corneal involvement and is in the early symptomatic stage, mast cell stabilizers are preferred. [cite:Khurana Comprehensive Ophthalmology Ch 4]