Eyeworld

EW NEWS & OPINION January 2011 17 G rading systems have suc- cessfully been used for a variety of ophthalmic conditions including cataract and diffuse lamel- lar keratitis. Now vernal keratocon- junctivitis (VKC) is getting its own system along with a standardized therapeutic approach for treatment. "This grading system allows for identifying the more severe forms of VKC that are at higher risk of recurrences, corneal ulcera- tion, and worse final visual out- come," according to a report by Stefano Bonini, M.D., department of ophthalmology, University of Rome, Rome, and colleagues. The re- port was published online in April 2010 in Ophthalmology. "We developed a decision tree for VKC treatment that accurately reflects the clinical grading of the disease," Dr. Bonini wrote. The deci- sion tree "can be easily applied to patients by any ophthalmologist," he noted. Grading and treating Dr. Bonini included 207 VKC pa- tients in his study to investigate the new grading system as well as a deci- sion tree developed by CART (classi- fication and regression tree) analysis to more effectively manage the dis- ease. "These patients underwent from 1 to 9 examinations per year and showed a great variability of clinical manifestations with improvement or worsening of clinical signs and symptoms up to 8 times per year," Dr. Bonini reported. "Such high clin- ical variability forces the physician to almost constantly check and modify a patient's treatment. A sim- ple clinical decision tree and a grad- ing system that allow ophthalmologists to share a com- mon language in the assessment and treatment of VKC and in the devel- opment of clinical trials on potential new therapeutic compounds would greatly improve the management of this challenging disease." Dr. Bonini retrospectively ana- lyzed therapies used for these pa- tients and developed a decision tree using CART. The decision tree used to place patients in the various grading cate- gories can be seen in Figure 1. "The decision tree obtained al- lowed us to identify 5 classes of VKC severity, characterized by different signs and symptoms and requiring different therapeutic approaches," Dr. Bonini reported. Sixteen patients were in the grade 0 category (absence of symp- toms and no therapy); 59 patients were deemed to be grade 1 (presence of symptoms without photophobia, occasional use of anti-allergic eye drop); 74 patients were classified as grade 2 (presence of symptoms in- cluding photophobia, daily anti-al- lergic treatment); 22 patients—who had superficial punctuate keratopa- thy (SPK)—were determined to be grade 3 (daily anti-allergic treatment associated with occasional topical steroid); and 36 patients were in the grade 4 category (diffuse SPK or corneal ulcer; pulsed high-dose topi- cal steroid). "Our analysis identified the presence of ocular symptoms and corneal involvement as the 2 most important features of VKC that in- fluence therapy," Dr. Bonini re- ported. "The overall presence and severity of ocular symptoms should be considered the foremost parame- ter when prescribing topical anti-al- lergic therapy, such as antihistamine, mast-cell stabilizers, and multiple-action compounds." Some factors, such as itching and conjunctival papillae, were pres- ent in all stages of disease and there- fore were not relevant to prudent splitting criteria in the decision tree. They nonetheless remain the main diagnostic criteria of the disease. Photophobia is, however, an im- portant factor in determining a pa- tient's VKC grade. "Among ocular surface symptoms, the presence of photophobia seems to discriminate the most severe stages, which are mostly characterized by corneal in- volvement. In these cases, topical steroids are successfully used to con- trol ocular inflammation," Dr. Bonini reported. But until the decision tree and grading system gain wider accept- ance, physicians may be more com- fortable relying on their own methods to treat VKC. For example, in milder VKC, Su- jatha Mohan, M.D., Rajan Eye Care Hospital, Chennai, India, said she would put patients on antihistamine drops and tear substitutes. In pa- tients with advanced VKC, she would look to steroids for assistance, starting with fluorometholone. In more severe patients, she would con- sider loteprednol and finally, pred- nisolone acetate in advanced cases. "I do get some patients with ad- vanced VKC who have to be on prednisolone acetate drops and re- ceive cryo for papillae under the tarsal conjunctiva," Dr. Mohan said. "We also have patients with epithe- lial plugs that have to be taken care of. They definitely need high-dose steroids." Dr. Bonini seems confident that the standardized grading system will nonetheless be useful. "This new grading system will also allow us to identify severe forms of VKC, pa- tients who are at higher risk of de- veloping recurrences, corneal ulcer, and a worse final visual outcome, and should therefore be followed by ophthalmologists on a more fre- quent basis or addressed to referral centers for corneal diseases," Dr. Bonini concluded. EW Editors' note: Dr. Bonini has no finan- cial interests related to this study. Dr. Mohan has no financial interests re- lated to her comments. Contact information Bonini: s.bonini@unicampus.it Mohan: +91 044 2834 0500, rajaneye@md2.vsnl.net.in by Matt Young EyeWorld Contributing Editor A decision tree for VKC Grade 4 very severe N=36 Grade 3 severe N=22 Grade 2 Moderate N=74 Grade 1 Mild N=50 Grade 0 Quiescent N=16 Prescience of Ocular sysmptoms? N=207 Prescience of photophobia? N=166 Mild to moderate SPK? N=94 Severe SPK and/or Corneal? ulcer N=191 Yes Yes Yes Yes No No No No VKC Patients N-207

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