Spring catarrh

Vernal catarrh (vernal keratoconjunctivitis) is an allergic disease that affects only the conjunctiva and cornea. Until the 1950s, the disease was considered a rare eye pathology. Over the past decades, significant progress has been made in the development of issues of epidemiology, pathogenesis, diagnostics, clinical picture, and treatment of vernal catarrh.

Vernal catarrh is a recurrent, bilateral inflammation that primarily affects boys living in warm, dry climates. It is an allergic disorder in which IgE and cell-mediated immune mechanisms play an important role. Three-quarters of patients have associated atony, and two-thirds have a family history of atopy. These patients often develop asthma and eczema in childhood. Vernal keratoconjunctivitis usually begins after age 5 and continues until puberty, occasionally persisting for over 25 years.

Vernal catarrh may be seasonal, with a peak in late spring and summer, although many patients have the disease year-round. Keratoconus is common in patients with vernal keratoconjunctivitis, as are other types of corneal ectasia, such as pellucid marginal degeneration and keratoglobus.

Spring catarrh occurs in various parts of the globe: most often in countries with hot climates (in Africa, South Asia, the Mediterranean), much less often in northern countries (Sweden, Norway, Finland). There is no precise data on its prevalence in the world to date. In our country, it is most common in the southern regions, as well as in Central Asia.

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The cause of spring catarrh has not yet been fully clarified. Painful symptoms are especially evident in spring and summer. It is believed that the disease is caused by ultraviolet rays with increased sensitivity to them.

Spring catarrh is usually observed in boys, begins at the age of 4, lasts for several years, worsens in the spring and summer, and completely regresses during puberty, regardless of the treatment methods used. These facts indicate a certain role of endocrine changes in the growing organism.

Spring catarrh is characterized by pronounced seasonality: it begins in early spring (March-April), reaches its maximum in summer (July-August), and regresses in autumn (September-October). In the southern regions of our country, as a rule, the exacerbation of the disease begins in February and ends in October-November. Year-round course of the disease is observed in people with a burdened allergic history (food and drug allergies) or concomitant allergies (eczema, neurodermatitis, vasomotor rhinitis, bronchial asthma). The seasonality of the disease is less pronounced in countries with tropical and subtropical climates.

The main symptoms are intense itching of the eyes, which may be accompanied by lacrimation, photophobia, a foreign body sensation and burning; copious mucous discharge and ptosis are also common.

Spring catarrh begins with a slight itch in the eyes, which, progressively increasing, becomes unbearable. The child constantly rubs his eyes with his hands, which makes the itch even worse. Itching typically increases in the evening. Sleep is disturbed, the child becomes irritable, disobedient, which forces parents to consult a neuropsychiatrist. Prescribing sleeping pills and sedatives is ineffective: they often worsen the course of the disease, complicating it with drug allergy.

The painful itching is accompanied by a thread-like discharge. Thick white threads of mucous discharge can form spiral accumulations under the upper eyelid, which causes particular concern to patients, increasing the itching. The threads are removed with a cotton swab, not always easily due to their stickiness, but without damaging the epithelium of the mucous membrane. Photophobia, lacrimation, blepharospasm, and visual impairment are associated with corneal damage. Usually, both eyes are affected to the same extent. With unilateral damage, especially in young children, torticollis is observed, requiring long-term treatment.

The symptoms of spring catarrh are so typical that in the severe form the diagnosis does not present any difficulties. Only old forms of the disease are differentiated from trachoma, allergic drug conjunctivitis, follicular conjunctivitis, sometimes with phlyctepular keratoconjunctivitis.

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There are three main forms of spring catarrh:

• palpebral, or tarsal;
• limbal, or boulevard;
• mixed.

The tarsal form of vernal catarrh is characterized by the formation of papillary growths in the upper eyelid in the form of a cobblestone pavement. The papillae are pale pink, flat, sometimes large in size. Typical thread-like viscous discharge. In the initial stages, before the appearance of papillae, the conjunctiva is thickened, matte (milky).

Vernal limbitis, or the bulbar form of vernal catarrh, is characterized by changes in the prelimbal conjunctiva of the eyeball and the limbus itself. Most often, in the area of the eye slit, a proliferation of yellow-gray or pinkish-gray tissue is found, having a gelatinous appearance. Framing the limbus, this tissue rises above it as a dense ridge, sometimes cystically altered. In cases of strict focality and flat lesions, as well as possible pigmentation of the newly formed tissue, a nevus of the limbal conjunctiva is often suspected.

A patient with annular lesions of the prelimbal conjunctiva and severe infection of the surrounding conjunctiva makes a severe impression. However, even in these cases, the conjunctiva of the upper eyelid is usually slightly altered, the cornea remains transparent, so visual acuity does not decrease. Newly formed tissue can grow on the limbus and on the cornea. Its surface is uneven, shiny with prominent white dots and Trantas spots consisting of eosinophils and degenerated epithelial cells. Depressions in the limbus, sometimes called Trantas pits, indicate regression of the disease.

Corneal damage in spring catarrh often develops with severe tarsal changes and usually leads to visual acuity impairment. Following the expansion of the upper limbus, micropannus may develop, extending no more than 3-4 mm onto the cornea. Sometimes, pronounced corneal dryness with a dryish paraffin-like coating tightly fused with the underlying corneal epithelium is observed along the upper limbus. In superficial punctate keratitis, the upper third of the cornea is also affected.

Corneal epitheliopathy is expressed in the appearance of point, sometimes larger areas of light staining of the cornea with fluorescein. Less often, clearly delineated large areas of corneal erosion are found, usually in the paracentral region. The bottom of the erosion is clean, the epithelial defect is quickly restored with treatment.

In case of infiltration, a flat superficial corneal ulcer may form on the eroded surface.

If the erosion has been present for a long time, its surface may be covered with a dry film, the edges of which slightly lag behind the underlying corneal tissue and easily break off if picked up with a scalpel. In the center, the film is tightly fused with the cornea, and can only be removed with great effort.

Stromal infiltrates and purulent corneal ulcers in spring catarrh are observed in cases of secondary infection or complications from taking medications.

In case of mild course, instillations of alomid and (or) lecrolin are performed 3 times a day for 3-4 weeks. In case of severe course, use persalerg or allergoftal 2 times a day. In the treatment of spring catarrh, a combination of antiallergic drops with corticosteroids is necessary: instillations of dexanos, maxidex or oftan-dexamethasone eye drops 2-3 times a day for 3-4 weeks. Additionally, antithystamine drugs (diazolin, suprastin or claritin) are prescribed orally for 10 days. In case of corneal ulcer, reparative agents are used (vitasik, taufon eye drops or solcoseryl gel, root gel) 2 times a day until the cornea condition improves. In case of long-term, persistent course of spring catarrh, a course of treatment with histoglobulin is carried out (4-10 injections).