Topical Corticosteroids Effective for VKC in Children, Young Adults

Topical corticosteroids may be more efficacious for the treatment of vernal keratoconjunctivitis in children and young adults than other therapeutics, according to the results of a systematic review published in Acta Ophthalmologica. 

Researchers conducted a systematic literature review and network meta-analysis of the currently published randomized clinical trial literature comparing the efficacy of medical treatments for VKC in children and young adults. 

Thirty-nine studies for eligible for both qualitative and quantitative review and included a total of 2118 participants. Primary analysis sizes varied, ranging from 11 to 364 patients (median, 28), and patient mean age range was 7 to 18 years. VKC ranged from non-active disease to VKC with disease-related corneal complications. 

Studies evaluated the efficacy of numerous medications, including topical mast cell stabilizers (n=22), topical dual-acting agents (n=4), topical corticosteroids (n=6), topical non-steroid anti-inflammatory drugs (n=3), topical calcineurin inhibitors (n=19), topical mitomycin (n=1), topical cytokines (n=1), and non-topical treatment modalities (n=3). Duration of studies ranged from 2 weeks and 3.9 years (interquartile range, 4-16 weeks). 

Roughly half of the included studies had either some concern or a high risk for bias. Per the researchers, only a few studies included “an appropriate analysis for estimating the effect of assignment to intervention.” 

Twenty studies were eligible for the network meta-analysis on itching. Significant itching relief was found with ketorolac tromethamine, mipragoside, mitomycin C, dexamethasone, cyclosporine, ketitofen fumarate, levocabastine, and sodium nedocromil. Sixteen studies were included in the network meta-analysis for tearing. Compared with placebo, significant tearing relief was seen with combination tacrolimus/olopatadine, tacrolimus, levocabastine, and mitomycin C. NAAG was associated with a significant worsening of tearing. 

Seventeen studies showed a significant relief of photophobia with mitomycin C, ketorolac, tromethamine, cyclosporine, dexamethasone, levocabastine, and ketitofen fumarate. Ten studies were included in the analysis of foreign body sensation. Significant relief was seen with ketorolac tromethamine and cyclosporine. 

Fourteen studies were included on hyperaemia, and eleven were included in punctate keratitis. For the first group of studies, significant improvement was associated with tacrolimus, mipragoside, dexamethasone, and cyclosporine; the second group found significant improvement with ketorolac tromethamine, cyclosporine, dexamethasone, ketitofen fumarate, and sodium nedocromil. 

Finally, 15 and 14 studies were evaluated for Horner-Trantas dots and macropapillae, respectively. Significant improvement for Horner Trantas dots was seen with mitomycin C, sodium cromoglycate, and sodium nedocromil; for macropapillae, significant improvement was seen with sodium nedocromil and mitomycin C. NAAG use was associated with significant worsening of macropapillae. 

Study limitations include differences in the populations of analyzed studies, a lack of reports of standard deviations for some outcomes, and the small number of studies available for the meta-analysis. 

“Efficacy of therapy differs across symptoms and signs,” the research concludes. “Going forward, consensus-based core outcomes may provide some basis for better comparison of efficacy. Further studies are warranted, especially considering the role of corticosteroids which seem to have high efficacy in outcomes evaluated in this study.” 

Reference

Ramussen MLR, Schou MG, Bach-Holm D, et al. Comparative efficacy of medical treatments for vernal keratoconjunctivitis in children and young adults: A systematic review with network meta-analysis. Acta Ophthalmol. Published online March 28, 2021.  doi:10.1111/aos.14858