Corneal Diseases in Children: Allergic Diseases

  • Andrea Cruzat
  • Kathryn Colby
Part of the Essentials in Ophthalmology book series (ESSENTIALS)


Allergies occur frequently in all pediatric age groups, affecting up to 40% of children, with a peak age in late childhood and young adulthood. It affects the health and overall quality of life of children and their families. Patients frequently have a history of other atopic diseases, such as eczema, asthma, or, most commonly, rhinitis. Allergic conjunctivitis is the most common ocular allergy syndrome among children, with atopic keratoconjunctivitis and vernal keratoconjunctivitis being less common but potentially more severe forms of ocular allergy. Symptoms include bilateral involvement, itching, tearing, mucoid discharge, redness, eyelid edema, and chemosis. IgE and non-IgE-mediated mechanisms are involved in the development of ocular allergic eye disease. The multiple mediators and pathways are differently expressed in the different allergic disorders, inducing the distinctive clinical aspects, diagnostic features, and response to treatment. There are a variety of pharmacological interventions that are available such as vasoconstrictors/histamine (H1) receptor blockers, mast cell stabilizers, multi-action agents, topical ophthalmic corticosteroids, topical nonsteroidal anti-inflammatory drugs (NSAIDs), topical cyclosporine, and tacrolimus as well as systemic drugs. Immunotherapy is also considered in the treatment of persistent severe cases. Despite all the available therapeutic agents, there continues to be a constant need to discover more effective ways to treat the different allergic eye disorders. In this chapter, we review the clinical features, diagnosis, potential complications, and treatment of these ocular allergic pediatric conditions. Early detection is necessary to prevent potentially serious consequences that could be sight threatening. Involvement of pediatric ophthalmologists and cornea specialists may be necessary to avoid preventable vision loss in severe cases.


Allergic conjunctivitis Seasonal conjunctivitis Perennial conjunctivitis Vernal keratoconjunctivitis Atopic keratoconjunctivitis 


Compliance with Ethical Requirements

Kathryn Colby and Andrea Cruzat declare that they have no conflict of interest. No human studies or animal studies were carried out by the authors for this article.


  1. Abelson MB, Granet D (2006) Ocular allergy in pediatric practice. Curr Allergy Asthma Rep 6:306–311CrossRefPubMedGoogle Scholar
  2. Abelson MB, Paradis A, George MA et al (1990) Effects of Vasocon-A in the allergen challenge model of acute allergic conjunctivitis. Arch Ophthalmol 108:520–524CrossRefPubMedGoogle Scholar
  3. Abelson MB, Leonardi AA, Smith LM et al (1995) Histaminase activity in patients with vernal keratoconjunctivitis. Ophthalmology 102:1958–1963CrossRefPubMedGoogle Scholar
  4. Abu-El-Asrar AM, Al-Kharashi SA, Al-Mansouri S et al (2001a) Langerhans’ cells in vernal keratoconjunctivitis express the costimulatory molecule B7-2 (CD86), but not B7-1 (CD80). Eye (Lond) 15:648–654. doi: 10.1038/eye.2001.202 CrossRefGoogle Scholar
  5. Abu-El-Asrar AM, Fatani RA, Missotten L, Geboes K (2001b) Expression of CD23/CD21 and CD40/CD40 ligand in vernal keratoconjunctivitis. Eye (Lond) 15:217–224. doi: 10.1038/eye.2001.65 CrossRefGoogle Scholar
  6. Abu-El-Asrar AM, Van Aelst I, Al-Mansouri S et al (2001c) Gelatinase B in vernal keratoconjunctivitis. Arch Ophthalmol 119:1505–1511CrossRefPubMedGoogle Scholar
  7. Awwad ST, Najjar DM, Arlette A, Haddad RS (2006) Vernal keratoconjunctivitis presenting unilaterally. J Pediatr Ophthalmol Strabismus 43:179–180PubMedGoogle Scholar
  8. Ballow M, Mendelson L (1980) Specific immunoglobulin E antibodies in tear secretions of patients with vernal conjunctivitis. J Allergy Clin Immunol 66:112–118CrossRefPubMedGoogle Scholar
  9. Bielory L (2000) Allergic and immunologic disorders of the eye. Part II: ocular allergy. J Allergy Clin Immunol 106:1019–1032. doi: 10.1067/mai.2000.111238 CrossRefPubMedGoogle Scholar
  10. Bielory B, Bielory L (2010) Atopic dermatitis and keratoconjunctivitis. Immunol Allergy Clin N Am 30:323–336. doi: 10.1016/j.iac.2010.06.004 CrossRefGoogle Scholar
  11. Bonini S (2004) Atopic keratoconjunctivitis. Allergy 59(Suppl 78):71–73. doi: 10.1111/j.1398-9995.2004.00570.x CrossRefPubMedGoogle Scholar
  12. De Smedt S, Wildner G, Kestelyn P (2013) Vernal keratoconjunctivitis: an update. Br J Ophthalmol 97:9–14. doi: 10.1136/bjophthalmol-2011-301376 CrossRefPubMedGoogle Scholar
  13. Foster CS, Calonge M (1990) Atopic keratoconjunctivitisGoogle Scholar
  14. Friedlaender MH (2011) Ocular allergy. Curr Opin Allergy Clin Immunol 11:477–482. doi: 10.1097/ACI.0b013e32834a9652 CrossRefPubMedGoogle Scholar
  15. Gradman J, Wolthers OD (2006) Allergic conjunctivitis in children with asthma, rhinitis and eczema in a secondary outpatient clinic. Pediatr Allergy Immunol 17:524–526. doi: 10.1111/j.1399-3038.2006.00429.x CrossRefPubMedGoogle Scholar
  16. Hooks MA (1994) Tacrolimus, a new immunosuppressant—a review of the literature. Ann Pharmacother 28:501–511CrossRefPubMedGoogle Scholar
  17. Irani AM, Butrus SI, Tabbara KF, Schwartz LB (1990) Human conjunctival mast cells: distribution of MCT and MCTC in vernal conjunctivitis and giant papillary conjunctivitis. J Allergy Clin Immunol 86:34–40CrossRefPubMedGoogle Scholar
  18. Jenmalm MC, Van Snick J, Cormont F, Salman B (2001) Allergen-induced Th1 and Th2 cytokine secretion in relation to specific allergen sensitization and atopic symptoms in children. Clin Exp Allergy 31:1528–1535CrossRefPubMedGoogle Scholar
  19. Kumagai N, Fukuda K, Fujitsu Y et al (2006) Role of structural cells of the cornea and conjunctiva in the pathogenesis of vernal keratoconjunctivitis. Prog Retin Eye Res 25:165–187. doi: 10.1016/j.preteyeres.2005.09.002 CrossRefPubMedGoogle Scholar
  20. Kumar S (2009) Vernal keratoconjunctivitis: a major review. Acta Ophthalmol 87:133–147. doi: 10.1111/j.1755-3768.2008.01347.x CrossRefPubMedGoogle Scholar
  21. La Rosa M, Lionetti E, Leonardi S et al (2011) Specific immunotherapy in children: the evidence. Int J Immunopathol Pharmacol 24:69–78CrossRefPubMedGoogle Scholar
  22. La Rosa M, Lionetti E, Reibaldi M et al (2013) Allergic conjunctivitis: a comprehensive review of the literature. Ital J Pediatr 39:18. doi: 10.1186/1824-7288-39-18 CrossRefPubMedPubMedCentralGoogle Scholar
  23. Leonardi A, DeFranchis G, Zancanaro F et al (1999) Identification of local Th2 and Th0 lymphocytes in vernal conjunctivitis by cytokine flow cytometry. Invest Ophthalmol Vis Sci 40:3036–3040PubMedGoogle Scholar
  24. Leonardi A, Fregona IA, Plebani M et al (2006) Th1- and Th2-type cytokines in chronic ocular allergy. Graefes Arch Clin Exp Ophthalmol 244:1240–1245. doi: 10.1007/s00417-006-0285-7 CrossRefPubMedGoogle Scholar
  25. Leonardi A, De Dominicis C, Motterle L (2007) Immunopathogenesis of ocular allergy: a schematic approach to different clinical entities. Curr Opin Allergy Clin Immunol 7:429–435. doi: 10.1097/ACI.0b013e3282ef8674 CrossRefPubMedGoogle Scholar
  26. Leonardi A, Motterle L, Bortolotti M (2008) Allergy and the eye. Clin Exp Immunol 153(Suppl 1):17–21. doi: 10.1111/j.1365-2249.2008.03716.x CrossRefPubMedPubMedCentralGoogle Scholar
  27. Miyoshi T, Fukagawa K, Shimmura S et al (2001) Interleukin-8 concentrations in conjunctival epithelium brush cytology samples correlate with neutrophil, eosinophil infiltration, and corneal damage. Cornea 20:743–747CrossRefPubMedGoogle Scholar
  28. Pucci N, Novembre E, Lombardi E et al (2003) Atopy and serum eosinophil cationic protein in 110 white children with vernal keratoconjunctivitis: differences between tarsal and limbal forms. Clin Exp Allergy 33:325–330CrossRefPubMedGoogle Scholar
  29. Saari KM (2010) Updates in the treatment of ocular allergies. J Asthma Allergy: 149. doi: 10.2147/JAA.S13705
  30. Sánchez Ferreiro AV, Muñoz Bellido L (2013) Tacrolimus in the treatment of atopic kerato-conjunctivitis. Arch Soc Esp Oftalmol 88:329–330. doi: 10.1016/j.oftal.2012.09.023 CrossRefPubMedGoogle Scholar
  31. Sridhar MS, Gopinathan U, Rao GN (2003) Fungal keratitis associated with vernal keratoconjunctivitis. Cornea 22:80–81CrossRefPubMedGoogle Scholar
  32. Tabbara KF (1999) Ocular complications of vernal keratoconjunctivitis. Can J Ophthalmol 34:88–92PubMedGoogle Scholar
  33. Takamura E, Uchio E, Ebihara N et al (2011) Japanese guideline for allergic conjunctival diseases. Allergol Int 60:191–203. doi: 10.2332/allergolint.11-RAI-0335 CrossRefPubMedGoogle Scholar
  34. Tesse R, Spadavecchia L, Fanelli P et al (2010) Treatment of severe vernal keratoconjunctivitis with 1% topical cyclosporine in an Italian cohort of 197 children. Pediatr Allergy Immunol 21:330–335. doi: 10.1111/j.1399-3038.2009.00948.x CrossRefPubMedGoogle Scholar
  35. Trocme SD, Sra KK (2002) Spectrum of ocular allergy. Curr Opin Allergy Clin Immunol 2:423–427CrossRefPubMedGoogle Scholar
  36. Trocmé SD, Kephart GM, Bourne WM et al (1993) Eosinophil granule major basic protein deposition in corneal ulcers associated with vernal keratoconjunctivitis. Am J Ophthalmol 115:640–643CrossRefPubMedGoogle Scholar
  37. Trocmé SD, Hallberg CK, Gill KS et al (1997) Effects of eosinophil granule proteins on human corneal epithelial cell viability and morphology. Invest Ophthalmol Vis Sci 38:593–599PubMedGoogle Scholar
  38. Tuft SJ, Ramakrishnan M, Seal DV et al (1992) Role of Staphylococcus aureus in chronic allergic conjunctivitis. Ophthalmology 99:180–184Google Scholar
  39. Udell IJ, Gleich GJ, Allansmith MR et al (1981) Eosinophil granule major basic protein and Charcot-Leyden crystal protein in human tears. Am J Ophthalmol 92:824–828CrossRefPubMedGoogle Scholar
  40. Westland T, de Bruin-Weller MS, Van der Lelij A (2013) Treatment of atopic keratoconjunctivitis in patients with atopic dermatitis: is ocular application of tacrolimus an option? J Eur Acad Dermatol Venereol 27:1187–1189. doi: 10.1111/jdv.12022 CrossRefPubMedGoogle Scholar
  41. Wong AHC, Barg SSN, Leung AKC (2014) Seasonal and perennial allergic conjunctivitis. Recent Pat Inflamm Allergy Drug Discov 8:139–153Google Scholar
  42. Zicari AM, Nebbioso M, Lollobrigida V et al (2013) Vernal keratoconjunctivitis: atopy and autoimmunity. Eur Rev Med Pharmacol Sci 17:1419–1423PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Department of OphthalmologyHarvard Medical School/Massachusetts Eye and Ear InfirmaryBostonUSA
  2. 2.Pontificia Universidad Católica de ChileSantiagoChile
  3. 3.Department of Ophthalmology and Visual ScienceUniversity of ChicagoChicagoUSA

Personalised recommendations