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 Table of Contents  
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 1-6

Epidemiology of Vernal Keratoconjunctivitis (VKC) among children aged (12–15) years - Menofia Governorate, Egypt

1 Ophthalmology Department Berket El Saaba Ophthalmic Hospitals, Menoufia University, Menoufia, Egypt
2 Department of Ophthalmology, Menoufia University, Menoufia, Egypt
3 Department of Public Health and Community Medicine, Menoufia University, Menoufia, Egypt

Date of Submission17-Aug-2018
Date of Acceptance02-Oct-2018
Date of Web Publication28-Mar-2019

Correspondence Address:
Shaimaa S Soliman
Yasin Abdelghafar Street, Shebin Elkom City, Menoufia Governorate 32511
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/DJO.DJO_42_18

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Purpose The aim of this study was to study the prevalence and risk factors of vernal keratoconjunctivitis (VKC) among children aged 12–15 years in Menoufia Governorate.
Patients and methods This was a cross-sectional study that was carried out on 768 children (405 males and 363 females) aged from 12 to 15 years in Menoufia Governorate during the period from September 2016 to the end of August 2017. All participants were asked to answer a questionnaire and were subjected to full ophthalmological examination.
Results The mean age of the participants was 13.02±1.00 years. The prevalence of VKC among the studied children was 3.9% (95% confidence interval, 2.6–5.3). Exposure to dust and family history of allergy were the major risk factors (odds ratio, 16.04 and 45.25, respectively). Itching and burning sensation were the most prominent symptoms, whereas hyperemia was the most prominent sign.
Conclusion VKC is fairly common among children in Menoufia Governorate as part of the North African region. Exposure to dust and family history were the major risk factors. VKC was associated with other types of allergy like asthma or allergic rhinitis.

Keywords: allergic eye diseases, children, epidemiology, Menoufia, vernal keratoconjunctivitis

How to cite this article:
Ahmed SM, Ahmed KS, El Morsy OA, Soliman SS. Epidemiology of Vernal Keratoconjunctivitis (VKC) among children aged (12–15) years - Menofia Governorate, Egypt. Delta J Ophthalmol 2019;20:1-6

How to cite this URL:
Ahmed SM, Ahmed KS, El Morsy OA, Soliman SS. Epidemiology of Vernal Keratoconjunctivitis (VKC) among children aged (12–15) years - Menofia Governorate, Egypt. Delta J Ophthalmol [serial online] 2019 [cited 2022 May 19];20:1-6. Available from: http://www.djo.eg.net/text.asp?2019/20/1/1/255116

  Introduction Top

Typical vernal keratoconjunctivitis (VKC) is a chronic, recurrent, and seasonal allergic disorder, but in severe cases, it becomes perennial. VKC affects bulbar and palpebral conjunctiva and cornea of both eyes. Approximately 75% of the patients give a history of atopy, and of these, 2/3 of the patients give a family history of allergic disorder [1],[2].

VKC resolves spontaneously after a course of several years. It has a good prognosis in early stages, but in chronic recurrent disease, blinding complications can occur owing to corneal scarring and advanced steroid-induced glaucoma [3].

VKC is associated with intense itching, redness or brownness, lacrimation, photophobia, and a mucinous, ropy discharge containing eosinophils. It is a type 1 hypersensitivity reaction but with additional immune mechanisms involved in its pathogenesis. It has a global distribution with a widely varying incidence, as it is less common in Northern Europe and North America and more common in the African continent, the Mediterranean countries, Central and South America, and the Indian subcontinent [4],[5].

The affected children are usually in their first two decades of life, and although the majority of cases have a good prognosis and resolve spontaneously after puberty, potentially sight-threatening corneal changes occur in up to 10% of patients [5],[6].

VKC is an important cause of hospital referral among children in many parts of Africa [5],[7],[8], Asia [4], and the Middle East [6], with a prevalence of 5% reported for children in their first decade in Chad and Djibouti [9]. The pathogenesis of VKC is complex and involves environmental, endocrine, racial, and genetic factors [5],[10]. Many studies of allergic diseases show a rural environment to be protective, but the mechanism of this effect is unknown [11],[12]. Typically, VKC displays a seasonality such that recurrences develop in spring, but often the severity and precise timing of disease symptomatology are sporadic [13],[14],[15].

Recent epidemiological reports provide evidence of a genetic component to the disease. Studies of patients living in regions where the disease is rare (such as Europe) show that most VKC sufferers are first-generation or second-generation immigrants from areas where the disease is endemic [13],[16].

Menoufia Governorate is primarily an agricultural and rural area in the Egyptian Delta. This dusty and pollen-loaded environment increases the potential of allergic diseases including VKC especially in young age group. However, the magnitude of VKC is not well known among young people. So, this work was conducted to study the prevalence and risk factors of VKC among children aged 12–15 years in Menoufia Governorate.

  Patients and methods Top

A cross-sectional, descriptive analytical study was conducted from the first of September 2016 to the end of August 2017 on children aged between 12 and 15 years at Menoufia Governorate. Menoufia Governorate has a population of little bit over four million. The targeted age group (10–15 years) represented 9.5% of the population. Sample size calculation rendered 374 children to be included in this study [power 90%, 95% confidence interval (CI)]. The sample size was doubled to include more cities and towns. The districts were chosen by multistage random sampling, and then the children were recruited from schools, orphan houses, and social clubs by simple random sampling. All the eligible children in these classes were invited to participate. Contact lens wearers or children with ocular prosthesis were excluded from the study.

Ethical approval: all procedures performed in this study involving human participants were in accordance with the ethical standards of Menoufia Faculty of Medicine and the 1964 Helsinki declaration and its later amendments or comparable ethical standards and were approved by Menoufia University Research Committee before starting the research. The school administrative staff and guardians/participants were informed about the purpose of the study and the steps of ophthalmological examination. A written informed consent was taken from every participant’s guardian or caregiver before participation.

All the included children were interviewed using a questionnaire, which included the sociodemographic data (age, sex, and residence), symptoms (itching, blurring, discharge, redness, burning sensation, and photophobia), exposure to risk factors (chronic dust exposure, family history, and other allergic diseases), and seasonal variation (seasonal/perennial) related to VKC. Children with possible allergic eye diseases were referred to the Outpatient Clinics of the Ophthalmology Department of Menoufia University for full ophthalmological examination, which included the following:
  1. Assessment of visual acuity with Landolt’s C-Chart in an adequately lighted room.
  2. Slit lamp examination for anterior segment evaluation for perilimbal pigmentation, bulbar hyperemia, and tarsal papillae.
  3. Cycloplegic refraction and astigmatism were recorded.
  4. Fluorescein staining of the cornea to detect any epithelial erosions, keratitis, or shield ulcers.
  5. Fundus examination with +90 D lens on slit lamp to assess the optic nerve head.

The diagnostic criteria for VKC included severe itching, photophobia, foreign body sensation, mucous discharge, diffuse conjunctival injection, upper tarsal giant papillae, thickening and opacification of the limbal conjunctiva, perilimbal Horner–Tranta’s dots, punctate epithelial erosions or keratitis, plaques containing fibrin and mucous, shield ulcers, corneal neovascularization, and a waxing and waning gray–white lipid depositing in the peripheral, superficial stroma (pseudogerontoxon).

Statistical analysis

Data were analyzed by SPSS, version 23 (SPSS Inc., Released 2015, IBM SPSS statistics for Windows, version 23.0; IBM Corp., Armonk, New York, USA). Student’s t test was used for comparison of quantitative variables between two groups of normally distributed data. χ2 was used to study the association between qualitative variables. Whenever any of the expected cells were less than five, Fischer’s exact test with Yates correction was used. Two-sided P value of less than 0.05 was considered statistically significant.

  Results Top

The mean age of the studied 768 children was 13.00±1.00 years ranging from 12 to 15 years. Males represented 52.7% of all the studied group (405 children), whereas females represented 47.3% (363 children). A total of 155 (20.1%) children were suffering different types of eye allergy, of whom 114 (14.8%) had the seasonal type, 30 (3.9%) had VKC, and the remaining 10 (1.3%) had other types of allergy like phlyctenulosis or giant papillary conjunctivitis. The different types of VKC were distributed as mixed type (limbal and palpebral) in 46.6%, pure limbal (bulbar) type in 40%, and pure palpebral type in 13.3% ([Table 1]).
Table 1 Prevalence of different types of allergy among the studied group (N=768)

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The presence of VKC was significantly related to living in a rural area [odds ratio (OR), 2.4; 95% CI, 1.09; 5.35], continuous exposure to dust (OR, 16.04; 95% CI, 4.93; 52.22), and presence of family history of allergy (OR, 45.25; 95% CI, 12.83; 159.58). Other forms of systematic allergy like allergic rhinitis, asthma, and eczema were significantly associated with VKC, as their prevalence was higher in children with VKC than in normal children (P<0.001 and 0.01, respectively, [Table 2]).
Table 2 Risk factors and other allergies associated with vernal keratoconjunctivitis (N=644)

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No significant difference was observed regarding sex distribution between normal and VKC children ([Table 2]).

Symptoms of ocular irritation such as itching, tearing, burning, discharge, redness, and photophobia were all significantly higher in children with VKC than other children. Ocular signs of VKC like palpebral papillae, conjunctival hyperemia, follicles, pigmentations, and Tranta’s dots were also significantly higher in children with VKC than in normal children. Corneal epithelial erosions and keratitis were the most frequent complications found in children with VKC ([Table 3]).
Table 3 Symptoms, signs, and complications of vernal keratoconjunctivitis

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  Discussion Top

Allergic conjunctivitis is common in childhood and adolescent age. Among the different varieties of allergic conjunctivitis, VKC is the most troublesome type [17].

In this study, the prevalence of allergic eye disease was 20.1%, and VKC represented 3.9% of eye allergies in children aged 12–15 years. This is near to other countries in the African continent like Rwanda (Central Africa) in the year 2011, where the prevalence was 4% [18], and in Ethiopia (2012), where it was found in 5.2% of children between 11 and 15 years [19]. Another survey among children aged 6–10 years in South Africa (1995) revealed a prevalence of VKC of 20.1% [20]. In two separate observations including a cross-sectional study from Nigeria, the first one (2010) showed VKC prevalence of 6.7% with age range between 4 and 15 years [21] and the second study (2013) showed a prevalence of 2.9% where the age of the cases ranged from 6 years to under 16 years [22]. The prevalence of VKC varied widely in different countries of the Middle East. In Jordan (2003) [23], VKC was found in 1.5% of the cases, whereas among Palestinians of East Jerusalem in the year 2000 [24], the disease accounted for 9.8%. In a study in Gaza strip (2014), 7.0% of the cases had VKC [25]. Another study done in Saudi Arabia in the year 2008 [26] revealed that vernal catarrh was the most common disorder accounting for 35.6% of the cases with age range between 0 and 16 years.

A sex difference has been observed in this study, as males represented 63.3% and females 36.7% among the VKC cases, making a male to female ratio of nearly 1.7 : 1. However, there was no significant difference in sex distribution between normal and VKC children. In Ethiopia, 63.4% of the cases were males and 36.6% were females, making a male to female ratio of 1.7 : 1 [19]. In the study by Sethi et al. [26], males (81%) were more affected than females (19%). Similar male predominance was found in another study at Tikrit, where males were 70.7% [27]. In Nigeria, the number of affected boys was almost double that of girls, making a male to female ratio of 1.8 : 1 [21], which is very similar to a study in Rwanda [18] and Italy, where male to female ratio was 2.4 : 1 [28] and 3.3 : 1 [29], respectively. There was male predominance, with ∼74% of the cases being males, whereas only ∼26% of the cases belonged to the female sex in India [30]. Similarly, a study was done in Pakistan in which males represented 88% of the cases in their early years [31]. In Yemen, the results were a little different, with a male : female ratio of 3.1 : 1 [32]. Other studies done by Bonini et al. [10], Leonardi et al. [29], and Kansakar [33] observed male predominance in patients under 20 years of age, among whom the male : female ratio was 4 : 1–3 : 1, whereas the ratio in those who were older than 20 years of age was nearly 1 : 1.

The major risk factors for VKC in the studied group were living in a rural area, continuous exposure to dust, and the presence of family history of allergy, especially allergic eye disease. A case–control study conducted in Rwanda showed that in severe VKC, exposure to dust was the main risk factor. It is believed that this is caused by conjunctival hyper-reactivity when nonspecific stimuli come in contact with the conjunctival mucosa [18]. In Ethiopia, a study found an association between family histories of the nonocular allergic diseases, such as asthma, atopic rhinitis, and eczema and VKC [11],[15]. A significant association was found between the presence of VKC and other types of nonocular allergies like allergic rhinitis (33.3), asthma (30.0%), and eczema (20.0%). The same was reported by Montan et al. [34] (in Sweden), Saboo et al. [35] (in India), and Kosrirukvongs et al. [36] (in Thailand). This is believed to be owing to common features in the immunopathology of asthma, bronchitis, eczema, and hay fever, including fixation of IgE molecules on the surface of mast cells and release of mediators such as histamine and prostaglandins, which mediate a type I immune reaction [28],[30],[37].

In the present study, itching and eye rubbing were the most frequent complaints. They were observed in all cases of VKC. The same was reported by a study in Nepal and a study in Karachi [38],[39]. Other studies show a little bit lower frequency of itching and rubbing: one in India, where itching was seen in 97.14% [30]; one in Nigeria, where itching was found in 71% [40]; and one in Rwanda, where it was found in 83.5% of the cases [18].

Tearing and photophobia came in order after itching and eye rubbing. Tearing was present in 66.7% and photophobia was found in 46.7% of the cases. Because it may be difficult to assess ocular symptom in young children, there was a wide variation in these symptoms in different studies. Tearing was present in 94.28% of the cases in India [30], in 79.4% of the cases in Rwanda [18], and in 33.5% of the cases in Nigeria [40]. In Karachi, photophobia was found in 16% of the cases [41] which is much lower than the present study. Some studies tried to explain this variation. Some believed that photophobia is caused by involvement of the cornea [42]. Others thought that photophobia and keratopathy are usually seen in patients with giant papillae [43]. The alteration of sub-basal and stromal corneal nerves was detected by confocal microscopy in the study done by Nebbioso and colleagues on patients with VKC. These alterations were correlated to the higher severity of photophobia [44].

The characteristic white ropy discharge of VKC was found in 46.7% of the cases in the present study, whereas in Nepal, it was found in 76.5%, and in Karachi, the discharge was present in 84% of the cases [38],[39].

In the present study, approximately one-half (53.3%) of the included group showed hyperemia and red eye and approximately two-thirds (80.0%) had burning sensation. A close percentage in Nigeria (62.5%) had hyperemia [40], whereas a higher percentage was observed in Nepal (76.5%) [38]. Burning sensation was almost similar to Rwanda (77%) [18] and Italy (90%) [43] but very different to Karachi (10%) [38].

Rao and Padmanabhan [45] described perilimbal pigmentation as a consistent finding in VKC. Increased spotty pigmentation of the interpalpebral exposed conjunctiva is common among patients from Africa and Asia, especially among very young children, but whether this sign is correlated with the disease activity or not is controversial [18],[46]. It was found in 60% of the present study group. It was also high in Rwanda (90.3%) [18], but very low in Nepal (14.7%) [39] and in India (11%) [35].The presence of Horner–Tranta’s dots, which tend to be more common in severe limbal VKC, was found to be relatively less frequent in this work as they were found in 13.3% of the cases. They were also low in Karachi (18%) [38]. However, their presence was higher in Gaza strip (30%) (25), in Thailand (46%) [36], and in India (57.14%) [30].

Complications generally had different rates in VKC cases. In this study, epithelial erosions were present in 20% of the cases and keratitis in 6.7%. Keratopathy was reported in 8.9% of VKC cases in Gaza strip [25], 22.0% in Thailand [36] and 24.0% in Karachi [38]. In India, superficial punctate keratitis was seen in 48.57% [30], and in Italy, it was seen in 55% of the cases [43].

There were no cases with shield ulcer in this study, whereas in Rwanda, it was found in 0.8% [18] and in 3.0% in India [35]. However, in Karachi, it has a slightly greater incidence, as it was found in 10% of VKC cases [38], and in Italy, it varied between 9.7 and 15.3% [10],[29].

This study observed that mixed (limbal and palpebral) type of the disease was the commonest type (46.6%) followed by pure limbal (bulbar) type (40%) and pure palpebral disease, which was the least observed type (13.3%). In Gaza strip, the results were similar to this study where mixed VKC was the commonest type (44.5%), followed by limbal type (36.4%), palpebral type (18.2%), and giant papillae (9.8%) [25]. In Ethiopia, limbal, mixed, and palpebral types of VKC were seen in 58.5, 29.3, and 12.2% of the cases, respectively [19]. On the contrary, in Nigeria, the most prevalent type was limbal (46.5%), followed by the mixed type (45.7%) and then the isolated tarsal (palpebral) type (7.8%) [40]. Italian patients, in the study of Zicari et al. [28], were more often affected by the tarsal form (71%) compared with 29% with mixed, whereas no child was affected by the limbal form. Another study in Italy done by Leonardi et al. [29] showed that 68.5% were affected by the tarsal form, 20.4% by the mixed form, and only 11.1% by the limbal type. In Asian countries like India, the isolated limbal form was present in 12.6%, whereas the isolated palpebral form was seen in 15.6% [35]. However, in Yemen, the palpebral form was present in 34.1%, the limbal form in 48.0% whereas the mixed form was present in 17.9% of the cases [32]. In Karachi, the palpebral form was observed in 58% followed by the mixed type in 26% and the limbal in 16% [38].

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  [Table 1], [Table 2], [Table 3]

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