Q:

9/24/2012
I have a 7 year old male patient followed by a ped ophthalmologist at a quaternary ped hospital in for such severe vernal keratoconjunctivitis that he is on cyclosporine and pred eye drops from February to October the past two years. Also severe atopic dermatitis.

Skin tests positive to birch and oak.

I am proposing a course of preseasonal tree pollen SCIT but dad is anxious re: any possible ocular side effects from treatment, as they are already seen q weekly or 2-weekly for the very labile situation in his eyes.

Do you have any sage advice and/or similar experience to inform my decision, beyond the lit on the utility of SCIT for allergic conjunctivitis?

A:

Thank you for your inquiry.

There are two issues involved in answering your question:
1. The first issue is whether or not there would be any ocular side effect to this treatment.

To my knowledge, there would be no ocular side effect from immunotherapy used to treat vernal conjunctivitis, and I believe that the results of the two studies (abstracts copied below) in the literature studying immunotherapy for vernal conjunctivitis in essence confirm this.

2. Would immunotherapy be effective for this condition?

To my knowledge, the only two studies looking at this issue are the ones noted above. Immunotherapy, therefore, has not been strongly validated as an effective treatment for vernal conjunctivitis. However, I can see no reason not to use it, based upon these studies, for recalcitrant cases.

Thank you again for your inquiry and we hope this response is helpful to you.

Cornea. 2012 May;31(5):525-8.
Subcutaneous allergen-specific immunotherapy versus topical treatment in vernal keratoconjunctivitis.
Mahdy RA, Nada WM, Marei AA.
Source
Department of Ophthalmology, Faculty of Medicine, Zagazig University, Zagazig, Sharkia, Egypt.
Abstract
Purpose: The study evaluated the treatment of cases with vernal keratoconjunctivitis by subcutaneous allergen-specific immunotherapy (SCIT) versus topical treatment according to clinical improvement and total serum immunoglobulin (Ig) E.
Design: Prospective randomized study.
Methods: The study included 64 patients with bilateral vernal keratoconjunctivitis. Cases were divided into 2 groups: group 1, 32 patients who were subjected to topical treatment; and group 2, 32 patients who were subjected to intradermal skin reactions to different allergens. Prepared subcutaneous injections of different allergens were administered. Follow-up was performed to detect criteria of improvement according to clinical data and total serum IgE.
Results: The study revealed that the treatment by SCIT was more effective in improving the clinical symptoms and reducing the serum IgE than topical treatment because there was a greater reduction in symptoms in group 1 of immunotherapy (72%) than in group 2 of medical treatment (59%) (P < 0.05). Also, there was a significant reduction in total serum IgE (P < 0.05) in group 1 (62%) compared to group 2 (42%). However, the intradermal test for each group of patients showed that 62% of the patients were sensitive to pollens, 19% to house dust, and 19% to more than one allergen.

Cutan Ocul Toxicol. 2010 Sep;29(3):198-202.
Hyposensitization in the treatment of resistant cases of vernal keratoconjunctivitis.
Mahdy RA, Nada WM, Shahien EA, Boghdadi GA, Marei AA.
Source
Department of Ophthalmology, Faculty of Medicine, Zagazig University, Zagazig, Sharkia, Egypt.
Abstract
Purpose: The study evaluated the treatment of resistant cases of vernal keratoconjunctivitis by hyposensitization resulting from intradermal skin reactions of different allergens.
Methods: This prospective study was carried out in the Department of Ophthalmology and the Department of Microbiology and Immunology, Zagazig University, and included 36 patients with bilateral vernal keratoconjunctivitis that was resistant to topical corticosteroids and antihistaminic drugs. Patients were subjected to intradermal skin reactions to different allergens after stoppage of the medication. Subcutaneous injections of different allergens were administered in addition to topical vasoconstrictor and antihistaminic eye drops for different durations of 12, 18, and 24 months.
Results: The study revealed that most of the patients were sensitive to pollens (65%), house dust (55%), and tobacco smoke (40%). Among 36 total patients who received different doses of allergens, 10 of 20 patients showed marked improvement following a 24-month treatment period, with a 50% success rate. Another 3 of 9 patients showed marked improvement following an 18-month treatment period, with a 33.3% success rate.
Conclusion: The use of intradermal skin reactions to determine the sensitivity for different stimulating allergens in resistant cases of vernal keratoconjunctivitis was conclusive. Treatment by hyposensitization using prepared vaccines had an acceptable success rate especially in patients treated for 24 months. Future studies will be needed to determine how effective this treatment is with other allergens and for longer durations of hyposensitization. Additional immunologic studies will be essential for developing a strategy of management of resistance in such cases of resistant vernal keratoconjunctivitis.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology