Vernal conjunctivitis is a sight-threatening inflammation of the membrane covering the back of the eyelid (tarsal conjunctiva). It primarily affects children younger than 14, and at least twice as many boys as girls have the condition. Many patients with vernal conjunctivitis also have asthma, allergies or eczema. Allergens that come into contact with the eye are believed to be at the root of the condition. It affects both eyes (bilateral) and occurs most often in hot, dry climates during the spring and summer.
Severe eye itchiness (pruritus) is a major symptom of vernal conjunctivitis. Large bumps (papillae) also typically appear in a cobblestone pattern on the membrane covering the back of the eyelid. In addition, tissue can become inflamed around the cornea (the transparent tissue at the front of the eye) where the white of the eye (sclera) and the cornea meet (limbus). This inflammation can scar the cornea and damage eyesight. This is the chief danger to vision of vernal conjunctivitis.
Symptoms of vernal conjunctivitis tend to be seasonal and often appear first in the spring. With proper medical attention, the condition is highly treatable and related vision damage is usually preventable.
About vernal conjunctivitis
Vernal conjunctivitis is an inflammation of the membrane covering the inner eyelid (tarsal conjunctiva). The condition is labeled "vernal" because it most often produces symptoms in the spring and summer. The term vernal means relating to, or occurring in the spring. Children under 14 are most likely to experience vernal conjunctivitis, with boys afflicted far more often than girls. Most children outgrow the condition by early adulthood.
During flare-ups, severe eye itchiness (pruritus) afflicts the patient. Large bumps (papillae) may develop in a cobblestone pattern on the membrane covering the back of the eyelid. Occasionally, these bumps are abrasive enough to the eyeball to cause a noninfectious scar on the cornea.
Those with vernal conjunctivitis should not let the condition go untreated. The tissue around the cornea where the white part of the eye (sclera) and the cornea meet (limbus) can become inflamed (limbal vernal conjunctivitis). If this inflammation extends onto the cornea itself, scarring and decreased vision may result.
The cause of vernal conjunctivitis is unknown, but the condition appears to be related to allergies. It often occurs in those with a family history of allergies or those who also have symptoms of allergic rhinitis, eczema or asthma. These symptoms together are a condition known as atopy.
Vernal conjunctivitis tends to strike children who live in hot, dry, dusty and windy climates. It is most often found in the Mediterranean, Middle East and West Africa, and is much less common in North America and Europe.
In most cases, vernal conjunctivitis is found in both eyes of the affected person (bilateral), but symptoms may be worse in one eye than the other.
Related allergies and conditions
Vernal conjunctivitis is one of several diseases caused by eye allergens. It is among the more dangerous diseases caused by eye allergies because it can permanently damage vision if left untreated.
Other diseases caused by eye allergies include:
Allergic conjunctivitis. An allergic reaction of the clear skin of the eye to an allergen such as pollen, mold or dander. It involves an inflammation of the conjunctiva (the thin, transparent membrane that covers the outer surface of the eye) and can result in itching, burning, and redness in the eye. Swollen eyelids, itching, watery eyes and clear eye discharge also are symptoms of allergic conjunctivitis. Vernal conjunctivitis is a chronic form of allergic conjunctivitis.
Atopic keratoconjunctivitis. A type of allergic conjunctivitis that is associated with atopic dermatitis of the eyelids, body and face. Symptoms include redness, itchiness, burning, tearing, stringy or ropy discharge and swelling. Age of onset is usually teens through early 20s, and patients often have a history of allergies, especially allergic rhinitis and/or asthma. Like vernal conjunctivitis, atopic keratoconjunctivitis can permanently alter vision if left untreated.
Giant papillary conjunctivitis. A type of conjunctivitis associated with contact lenses or other foreign bodies. This type of conjunctivitis is believed to be an allergic reaction involving proteins that stick to the surfaces of contact lenses, other prosthetic devices or surgical sutures. As the name implies, large bumps appear on the inner surface of the upper eyelids. This may also have nonallergy-related causes.
Signs and symptoms of vernal conjunctivitis
Symptoms of vernal conjunctivitis are usually seasonal, tending to flare up during the warmest parts of the spring and summer. However, some patients may have symptoms year-round. Exposure to wind, dust, bright light, hot weather or physical exertion often intensifies symptoms. In addition, the symptoms of vernal conjunctivitis tend to become milder as the patient gets older and most children outgrow the condition by early adulthood.
Unlike atopic keratoconjunctivitis, symptoms do not affect the skin of the eyelids and the eyelid margins. Instead, vernal conjunctivitis mostly affects the membrane lining the back of the eyelid (tarsal conjunctiva) and the area where the white of the eye and the cornea meet (limbus).
In most cases, vernal conjunctivitis is found in both eyes of the affected person (bilateral), but symptoms may be worse in one eye than the other. Signs and symptoms often associated with vernal conjunctivitis include:
Intense eye itchiness that may worsen with exposure to light, wind or dust. Hot temperatures or sweating due to exercise may also worsen eye itchiness associated with vernal conjunctivitis.
Excessive rubbing of the eyes.
Pain, especially when blinking or when eyes are closed.
Intense sensitivity to light (photophobia), including eye burning and pain.
Red eye with raised, white oozing skin lesions around the cornea (the eye's outermost layer).
Excessive tearing.
Blurred vision.
Sensation of foreign body in the eye.
Cobblestone pattern of bumps (papillae) and white mucus on inner-eyelid membrane.
Stringy, ropy discharge from the papillae on the inner-eyelid membrane.
Yellowish-white spots where the white of the eye and the cornea meet (limbus). These are known as Horner-Trantas dots.
Extra lower eyelid crease (Dennie’s line).
Corneal ulcer (open sore invading the cornea).
Cataract (clouding of the eye lens).
Individuals experiencing the signs and symptoms of vernal conjunctivitis should contact their physician.
Diagnosis and treatment
A physician will conduct a physical examination of the patient as well as compile a medical history and a list of symptoms.
If vernal conjunctivitis is suspected, scrapings of the conjunctiva may be performed. This usually will reveal elevated levels of activated T cells (a white blood cell involved in many immune system functions), eosinophils (a white blood cell involved in allergic reactions) and mast cells(cells involved in the creation of histamine during allergic reactions). In addition, tears from patients with vernal conjunctivitis often contain high levels of leukotrienes and histamine, which are chemicals that trigger symptoms during an allergic reaction.
Allergens that come into contact with the eye are believed to trigger vernal conjunctivitis. For this reason, patients may undergo allergy testing to determine the source of an allergic reaction. The most common method of identifying allergens is skin testing.
The key to treating vernal conjunctivitis is to prevent eyesight damage by making sure the condition does not affect the cornea. Low-dose corticosteroid eye drops are often prescribed to reduce inflammation and keep the cornea from being damaged. These must be used according to a physician’s orders, as overuse of corticosteroid eye drops can result in cataracts (clouding of the eye lens) and/or glaucoma (a group of diseases that occur when the normal fluid pressure inside the eyes slowly rises). They also increase the patient's risk for eye infection.
Mast cell stabilizer/antihistamine eye drops may be prescribed to treat the intense itching often associated with vernal conjunctivitis. Allergy shots (immunotherapy) may also be considered for the long-term treatment of vernal conjunctivitis.
Patients should be careful not to rub their eyes, as this will only irritate them and make symptoms worse. They may find relief from symptoms by using cold compresses, which are cloths or rags soaked in cold water and placed over the eyes.
In addition, patients should take steps to avoid or limit their contact with the allergens that trigger their symptoms.
Prevention methods for vernal conjunctivitis
There is no way to cure vernal conjunctivitis. However, patients can minimize symptoms and scarring by avoiding allergens that tend to serve as triggers. Dust mites and molds are common triggers for many who suffer from vernal conjunctivitis.
Managing and reducing symptoms is key to preventing damage of the cornea and permanent eyesight impairment associated with vernal conjunctivitis. Tips for reducing allergen exposure include:
Warm weather is a major trigger for vernal conjunctivitis. For that reason, use of air conditioning or a move to a cooler climate may reduce symptoms.
Dust and dust mites appear to trigger symptoms in many cases of vernal conjunctivitis. Patients should try to avoid such allergens by keeping their homes as dust-free as possible.
Limit time spent outside when pollen counts are high. Patients allergic to pollen may benefit from staying indoors during high pollen counts and windy or humid days.
Avoid exposure to mold. Patients allergic to mold should steer clear of damp areas (e.g., basements) and avoid doing lawn work (e.g., mowing, raking leaves).
Patients can also protect their eyes from wind and dust by wearing wrap-around sunglasses.
Artificial tears can also be used to rinse the eyes of allergens.
Questions for your doctor
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Parents may wish to ask their child’s doctor the following questions regarding vernal conjunctivitis:
Do my child’s symptoms suggest vernal conjunctivitis?
What methods will you use to determine if my child has vernal conjunctivitis?
What may have caused this condition in my child?
What treatment methods are available to my child?
Can my child spread the condition to others?
Does the condition pose a danger to my child's overall health?
What are the odds that my child’s sight will be permanently affected?
Will my child experience recurrence of symptoms in the future?
What steps can we take to avoid symptoms?
Will my child experience symptoms year-round or just at certain times of year?
What are the odds that my child will outgrow this condition?
Are my other children likely to develop this condition at some point as well?
