Vernal Keratoconjunctivitis (Spring catarrh)


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Vernal keratoconjunctivis (sometimes referred to as ‘Spring catarrh’) is a rare and potentially sight-threatening allergic disorder of children, characterised by chronic inflammation of the ocular surface (prevalence in Western Europe is 3.2 per 10,000 inhabitants).
More common in some other parts of the world, e.g. Mediterranean region, parts of Africa, Indian sub-continent
Complex immune reaction with raised IgE levels in the tears and serum, and mast cells and eosinophils in the conjunctival epithelium. T cells also play a significant role

Predisposing factors

Onset usually before 10 years of age; M:F = 2-4:1 and typically resolves during puberty
Seasonal exacerbations (hence name) but condition may be active year-round if severe
Patients usually atopic with a history of eczema and asthma
Often a family history of atopic disease

Symptoms of vernal keratoconjunctivitis

Ocular itching, burning or foreign body sensation
Mucoid stringy discharge
Blurred vision
Pain (if cornea affected)
Photophobia (may be intense)
Difficulty opening eyes on waking
NB: symptoms are typically bilateral but often asymmetrical in the two eyes

Signs of vernal keratoconjunctivitis

Grading scales (e.g. that of Bonini et al 2007) may be helpful in judging severity of disease
Stringy white mucous exudate
Palpebral, limbal and corneal manifestations:


  • hyperaemia and chemosis of conjunctiva when active
  • macro or giant tarsal papillae (1mm or greater in diameter; ‘cobblestone’ appearance)


  • hyperaemic, oedematous, thickened limbus
  • Trantas’s Dots (discrete white superficial accumulations of eosinophils and degenerating epithelial cells)
  • limbal phenotype may be unilateral

Corneal (usually in upper third)

  • punctate epithelial keratopathy
  • macro-erosion (coalescent epithelial loss)
  • plaque (deposited on Bowman’s layer, preventing re-epithelialisation); ‘shield ulcer’ in US terminology
  • subepithelial scarring (often ring-shaped)

NB: the signs are often asymmetrical in the two eyes
These patients may also have keratoconus and/or atopic cataract

Differential diagnosis

Atopic keratoconjunctivitis (usually in adults; around puberty, VKC may metamorphose into this disease). See Clinical Management Guideline on Atopic Keratoconjunctivitis

Management by optometrist

Practitioners should work within their scope of practice, and where necessary seek further advice or refer the patient elsewhere

Non pharmacological

Advise avoidance of specific environmental triggers (if known)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Cold compresses may reduce acute symptoms
(GRADE*: Level of evidence=low, Strength of recommendation=strong)


Mild disease:

Topical mast cell stabilisers e.g. gutt sodium cromoglicate 2%, gutt lodoxamide 0.1% or dual acting agents e.g. gutt olopatadine 0.1%,
gutt ketotifen 0.025% (off-label use) may provide symptomatic relief
Because of the sight-threatening nature of this condition, and the frequent need for other medical specialist involvement, maintain low threshold for referral to the ophthalmologist
(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)

Management category

Mild cases (without active limbal or corneal involvement, e.g. up to Bonini Grade 2a):

B2: Alleviation or palliation; no referral
Initial management with mast cell stabilizers. VKC requires careful monitoring for sight-threatening complications

B1: Possible prescription of drugs; routine referral
Routine referral if topical anti-allergy agents fail to provide symptomatic relief

If there is active limbal or corneal involvement:
A3: First aid measures followed by urgent referral (within one week) to an ophthalmologist

Possible management in secondary care or local primary/community pathways where available

Additional guidance may be available

VKC often requires a multi-disciplinary management approach (e.g. clinical immunologist, paediatrician). Other topical drugs used include steroids, immunosuppressants (e.g. ciclosporin, tacrolimus) and mucolytics (acetyl cysteine).
Manual or laser surgery may be required for the removal of corneal plaque

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (

Sources of evidence

Avunduk AM, Avunduk MC, Kapicioglu Z, Akyol N, Tavli L. Mechanisms and comparison of anti-allergic efficacy of topical lodoxamide and cromolyn sodium treatment in vernal keratoconjunctivitis. Ophthalmology. 2000;107:1333-7

Bonini S, Sacchetti M, Mantelli F, Lambiase A. Clinical grading of vernal keratoconjunctivitis. Curr Opin Allergy Clin Immunol. 2007;7(5):436-41

Bremond-Gignac D, Doan S, Amrane M, Ismail D, Montero J, Németh J, Aragona P, Leonardi A; Twelve-Month Results of Cyclosporine A Cationic Emulsion in a Randomized Study in Patients With Pediatric Vernal Keratoconjunctivitis. VEKTIS Study Group. Am J Ophthalmol. 2020;212:116-126

Brindisi G, Cinicola B, Anania C, De Castro G, Nebbioso M, Miraglia Del Giudice M, Licari A, Caffarelli C, De Filippo M, Cardinale F, Duse M, Zicari AM. Vernal keratoconjunctivitis: state of art and update on treatment. Acta Biomed. 2021;92(S7):e2021517.

De Smedt S, Nkurikiye J, Fonteyne Y, Tuft S, De Bacquer D, Gilbert C, Kestelyn P. Topical ciclosporin in the treatment of vernal keratoconjunctivitis in Rwanda, Central Africa: a prospective, randomised, double-masked, controlled clinical trial. Br J Ophthalmol. 2012;96:323-8

Ghiglioni DG, Zicari AM, Parisi GF, Marchese G, Indolfi C, Diaferio L, Brindisi G, Ciprandi G, Marseglia GL, Miraglia Del Giudice M. Vernal keratoconjunctivitis: An update. Eur J Ophthalmol. 2021;31(6):2828-2842.

Kim SE, Nowak V, Quartilho A, Larkin F, Hingorani M, Tuft S, Dahlmann-Noor A. Systemic interventions for severe atopic and vernal
keratoconjunctivitis in children and young people up to the age of 16 years. Cochrane Database Syst Rev. 2020;10(10):CD013298.

Leonardi A, Doan S, Amrane M, Ismail D, Montero J, Németh J, Aragona P, Bremond-Gignac D; VEKTIS Study Group. A Randomized, Controlled Trial of Cyclosporine A Cationic Emulsion in Pediatric Vernal Keratoconjunctivitis: The VEKTIS Study. Ophthalmology. 2019;126(5):671-681

Müller EG, Santos MSD, Freitas D, Gomes JÁP, Belfort R Jr. Tacrolimus eye drops as monotherapy for vernal keratoconjunctivitis: a randomized controlled trial. Arq Bras Oftalmol. 2017;80(3):154-158

Pradhan A, Pattanayak S, Dora J, Subudhi P. Effectiveness of a modified therapeutic protocol for the management of vernal
keratoconjunctivitis based on Bonini's graded clinical severity. Indian J Ophthalmol. 2022;70(7):2408-2414.

Singhal D, Sahay P, Maharana PK, Raj N, Sharma N, Titiyal JS. Vernal Keratoconjunctivitis. Surv Ophthalmol. 2019;64(3):289-311

Vichyanond P, Pacharn P, Pleyer U, Leonardi A. Vernal keratoconjunctivitis: a severe allergic eye disease with remodeling changes. Pediatr Allergy Immunol. 2014;25(4):314-22


What is Vernal Keratoconjunctivitis?

Vernal Keratoconjunctivitis (VKC), also known as Spring Catarrh, is a rare but serious allergic disease affecting the eyes of young children, especially boys, who usually have other allergic diseases such as eczema and/or asthma. It usually begins before the age of 10 years and often disappears at puberty, though it may change at that time into another allergic eye disease known as Atopic Keratoconjunctivitis.

Children with VKC complain of itching of the eyes, watering and a stringy discharge. Their vision may be blurred and they may be abnormally sensitive to light. A typical symptom is that they may have great difficulty in opening their eyes after waking. This and the very distracting effects of the condition may cause them to miss school.

VKC produces inflammation of the eye surface. On the underside of the upper eyelids, tiny bumps shaped like cobblestones appear. Substances released from this tissue can cause damage to the cornea (the clear window of the eye). Sometimes a whitish deposit, known as plaque, may accumulate on the cornea, which may also become scarred, causing problems with vision. 

How is Vernal Keratoconjunctivitis managed?

VKC is not a simple allergic condition like Seasonal Allergic Conjunctivitis (Hay Fever Conjunctivitis) as it involves various different types of immune reaction. This is why many cases need to be referred to the ophthalmologist, who in turn may refer them to other allergy specialists. Surgery is sometimes needed when plaque has accumulated on the cornea.

Vernal Keratoconjunctivitis (Spring catarrh)
Version 15
Date of search 08.12.22
Date of revision 23.02.23
Date of publication 29.03.23
Date for review 07.12.24
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