Transcript Ocular features of vernal keratoconjunctivitis in children requiring

OCULAR FEATURES OF
VERNAL KERATOCONJUNCTIVITIS
IN CHILDREN
REQUIRING TRABECULECTOMY WITH
MITOMYCIN-C FOR STEROID-INDUCED
GLAUCOMA
CORDELIA CHAN FRCSEd
MARCUS ANG MMed
DONALD TAN FRCOphth
FINANCIAL DISCLOSURES
CORDELIA CHAN
Consultant, Carl Zeiss Meditec (Travel Sponsorship)
MARCUS ANG
Nil
DONALD TAN
Patents / Royalty, NetWork Medical Products
The authors have no financial interest in the subject matter of this poster
VERNAL
KERATOCONJUNCTIVITIS
• Vernal keratoconjunctivitis (VKC) is
a severe form of ocular allergy that
affects mostly children and young
adults, with a prevalence of up to 515% amongst children
• The disease is often chronic and
persistent in the tropical climates in
Asia, unlike the seasonal
exacerbations seen in temperate
climates
• The chronic forms in Asians eyes
may be at high risk of permanent
visual impairment from corneal
scarring, cataract formation and
glaucoma secondary to
corticosteroid therapy
STEROID RESPONSE IN VKC
• “Steroid response” in
VKC can lead to a
secondary open-angle
glaucoma, which may
persist even after
corticosteroid therapy is
discontinued and the IOP
normalizes
• Patients with VKC
receiving corticosteroid
therapy have been
reported to be associated
with a 2-7% incidence of
glaucoma
PURPOSE
• We analysed cases of severe VKC with
corticosteroid-induced glaucoma in our Asian
population, and describe from these cases the
clinical profile of patients requiring
trabeculectomy with mitomycin-C (MMC).
• The risk factors for trabeculectomy as well as
the disease patterns and intraocular pressure
control following surgery are highlighted
MATERIALS AND METHODS
• A retrospective case-controlled review of medical records of all cases
of VKC seen in a single Center from 1 Jan 03 to 31 Dec 08. Data was
entered into standardized data collection forms designed specifically
for the study
• The disease severity was graded based on the definition by Bonini et
al. Clinical grade 3 and 4 (“severe” and “very severe”) were included
in the study
– Bonini S, Sacchetti M, Mantelli F, Lambiase A. Clinical grading of vernal
keratoconjunctivitis. Curr Opin Allergy Clin Immunol 2007 Oct;7(5):436-41.
• Corticosteroid-induced glaucoma was diagnosed if eyes had more
than two recordings of increased IOP > 21mmHg on Goldmann
applanation tonometry, and glaucomatous optic nerve head changes
or glaucomatous visual field defects on Humphrey 24-2 full threshold
testing
• The clinical profile of steroid responders with failed medical therapy
requiring trabeculectomy with MMC (0.02%, applied for 3-5min), and
their outcomes following surgery were documented.
RESULTS
• A total of 171 patients with severe VKC were reviewed, of
which 36 patients (21.0%) were found to have corticosteroidinduced glaucoma
• 6 patients (8 eyes) (16.7%) of these steroid responders
underwent trabeculectomy with MMC after failed medical
therapy
SUMMARY PROFILE OF PATIENTS REQUIRING
TRABECULECTOMY WITH MMC
•
•
•
•
•
Mean age: 9.3 years (+/-4.5)
Sex: All male
Mean maximum IOP: 38.8mmHg (+/-7.9)
Mean increase in IOP from baseline: 29.0mmHg (+/-8.2)
All had severe topical steroid dependent disease. 1 patient was
given a short-course of oral steroids
• All required two or more IOP lowering eyedrops pre-operatively
• Mean duration of disease at time of trabeculectomy: 7.2 years
PATIENTS REQUIRING TRABECULECTOMY WITH MMC
Patient
(Age/Sex
/Race)
4/M/c
5/M/i
7/M/i
7/M/c
13/M/c
14/M/c
Systemic
atopic
disease
and /or
family
history of
atopy
Duration
of disease
(years)
at time of
surgery
No. of
Recurren
ces
Y
4
Y
3
Peak
IOP
(mmHg)
Duration
of
steroid
use
(Weeks)
Main
steroid
used
3
35
9
12
31
18
Mean
Clinical
grade of
VKC
Preoperative
Mean
Clinical
grade of
VKC
Postoperative
R
Trabeculectomy
/ MMC
L: 3.934
R: 4.000
L: 1.000
R: 0.932
0.014
3
R&L
Trabeculectomy
/ MMC
L: 3.666
R: 4.000
L: 1.000
R: 1.022
0.035
L: 4.000
R: 0.534
L: 1.000
R: 0.534
0.001
No. of antiglaucoma
medications
Type of Surgery
D
2
D
P-value
Y
4
3
42
7
D
2
L
Trabeculectomy
/ MMC
Y
6
6
34
72
D
3
R
Trabeculectomy
/ MMC
L: 3.332
R: 3.668
L: 3.668
R: 0.932
0.001
Y
9
10
53
30
D
2
R&L
Trabeculectomy
/ MMC
L: 3.668
R: 3.934
L: 0.934
R: 0.934
0.030
2
L
Trabeculectomy
/ MMC
L: 3.268
R: 3.934
L: 0.866
R: 3.868
Y
6
8
38
39
PF
0.001
Demographics: Age= Presenting Age, M=Male, c= Chinese, i=Indian, m=Malay; Medical history: Y=Yes, N=No; Main
steroid used: D=Dexamethasone 0.1% Topical, PF= Predforte 1.0% Topical; Clinical grade of VKC: Based on modified
clinical grading by Bonini et al 8 weeks pre-operatively and duration of post-operative period.
RISK FACTORS FOR TRABECULECTOMY
• VKC patients with steroid response requiring
trabeculectomy with MMC were compared with those
treated medically
• This was performed with age and gender-adjusted
logistic regression
• Risk factors:
– Longer duration of steroid use (OR 1.1; 95%CI, 1.0-1.3;
p=0.035)
– Higher peak IOP (OR1.3; 95%CI, 1.0-1.5; p=0.017)
– Greater increase in IOP from baseline (OR 1.3; 95%CI, 1.0-1.5;
p=0.011)
• Multivariate analysis revealed this to be the most significant risk factor
– Other factors eg type of steroid used, type of VKC (ie limbal,
tarsal, mixed), corneal involvement or neovascularization were
not found to be significant
POST-TRABECULECTOMY OUTCOMES
VKC PATTERNS
•
•
Significant improvement in severity of
VKC post-trabeculectomy in all 8 eyes,
with reduced dependence on topical
steroids
Mean clinical grade of improvement 2.1;
95% CI, 1.3-3.0; p<0.001
IOP CONTROL
•
•
•
7 eyes had successful IOP control
following trabeculectomy
Mean IOP post-trabeculectomy :
9.74mmHg (+/- 4.1)
1 eye had trabeculectomy failure 18
months post-surgery. Repeat
trabeculectomy with MMC was
performed. Successful after 4 months to
date
Mean follow-up period post-trabeculectomy:
22.5 months (+/-15.3)
DISCUSSION
• The risk of corticosteroid-induced glaucoma in Asian
eyes with VKC may be higher due to the chronicity of the
disease and the long-term use of topical steroids, as in
the patients in our study
• Our study found important risk factors for trabeculectomy
in these cases to be longer duration of topical steroid
use, higher peak IOP and greater increase in IOP from
baseline
• The limitations of our study are its small numbers and
retrospective nature
DISCUSSION
• Mitomycin C is an antibiotic-anticancer agent that inhibits
DNA, RNA and protein synthesis and has a long-term effect
on cell proliferation. It induces prolonged localised inhibition of
Tenon’s fibroblasts, thus reducing trabeculectomy bleb
scarring. Its usefulness when applied topically in VKC has
been described
• In our study, following trabeculectomy with MMC, all eyes saw
significant improvement in the ocular surface requiring
minimal or no use of topical steroids for control of VKC
symptoms
• We postulate that the application of 0.02% MMC directly to
the bare sclera in the superior fornix during trabeculectomy
induces significant long-term inhibition of fibroblast and
inflammatory cells in the ocular surface, resulting in an
improvement in the signs and symptoms of VKC in our
patients
CONCLUSIONS
• Prolonged duration of topical steroid use and
greater increase in IOP from baseline are significant
risk factors for severe steroid response requiring
trabeculectomy in Asian patients with severe forms
of VKC
• Significant improvement in the signs and symptoms
of VKC is seen in eyes following trabeculectomy
with MMC. This could be related to the after-effects
of MMC on the ocular surface. This supports the
usefulness of MMC in the management of severe,
refractory forms of VKC
Singapore National Eye Centre
A Presentation by
the
Singapore National Eye Center