000064 vkc post trab poster wcc

7/30/2019 000064 VKC Post Trab Poster WCC

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OCULAR FEATURES OFVERNAL KERATOCONJUNCTIVITIS

IN CHILDRENREQUIRING TRABECULECTOMY WITHMITOMYCIN-C FOR STEROID-INDUCED

GLAUCOMACORDELIA CHAN FRCSEd

MARCUS ANG MMedDONALD TAN FRCOphth

FINANCIAL DISCLOSURES CORDELIA CHAN

Consultant, Carl Zeiss Meditec (Travel Sponsorship) MARCUS ANG

Nil DONALD TAN

Patents / Royalty, NetWork Medical Products

The authors have no financial interest in the subject matter of this poster


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VERNALKERATOCONJUNCTIVITIS

Vernal keratoconjunctivitis (VKC) isa severe form of ocular allergy thataffects mostly children and youngadults, with a prevalence of up to 5-15% amongst children

The disease is often chronic andpersistent in the tropical climates in

Asia, unlike the seasonalexacerbations seen in temperateclimates

The chronic forms in Asians eyesmay be at high risk of permanentvisual impairment from cornealscarring, cataract formation andglaucoma secondary tocorticosteroid therapy


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STEROID RESPONSE IN VKC Steroid response inVKC can lead to a

secondary open-angleglaucoma, which maypersist even after corticosteroid therapy isdiscontinued and the IOPnormalizes

Patients with VKCreceiving corticosteroidtherapy have beenreported to be associatedwith a 2-7% incidence of

glaucoma


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PURPOSE We analysed cases of severe VKC with

corticosteroid-induced glaucoma in our Asianpopulation, and describe from these cases theclinical profile of patients requiringtrabeculectomy with mitomycin-C (MMC).

The risk factors for trabeculectomy as well asthe disease patterns and intraocular pressure

control following surgery are highlighted


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MATERIALS AND METHODS A retrospective case-controlled review of medical records of all cases

of VKC seen in a single Center from 1 Jan 03 to 31 Dec 08. Data wasentered into standardized data collection forms designed specificallyfor the study

The disease severity was graded based on the definition by Bonini etal. Clinical grade 3 and 4 (severe and very severe) were included

in the study Bonini S, Sacchetti M, Mantelli F, Lambiase A. Clinical grading of vernal

keratoconjunctivitis. Curr Opin Allergy Clin Immunol 2007 Oct;7(5):436-41.

Corticosteroid-induced glaucoma was diagnosed if eyes had morethan two recordings of increased IOP > 21mmHg on Goldmannapplanation tonometry, and glaucomatous optic nerve head changesor glaucomatous visual field defects on Humphrey 24-2 full thresholdtesting

The clinical profile of steroid responders with failed medical therapyrequiring trabeculectomy with MMC ( 0.02%, applied for 3-5min ), andtheir outcomes following surgery were documented.


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RESULTS A total of 171 patients with severe VKC were reviewed, of

which 36 patients (21.0%) were found to have corticosteroid-

induced glaucoma 6 patients (8 eyes) (16.7%) of these steroid responders

underwent trabeculectomy with MMC after failed medicaltherapy

SUMMARY PROFILE OF PATIENTS REQUIRINGTRABECULECTOMY WITH MMC Mean age: 9.3 years (+/-4.5) Sex: All male Mean maximum IOP: 38.8mmHg (+/-7.9) Mean increase in IOP from baseline: 29.0mmHg (+/-8.2) All had severe topical steroid dependent disease. 1 patient was

given a short-course of oral steroids All required two or more IOP lowering eyedrops pre-operatively

Mean duration of disease at time of trabeculectomy: 7.2 years


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PATIENTS REQUIRING TRABECULECTOMY WITH MMC

Patient (Age/Sex /Race)

Systemicatopic

diseaseand /or

familyhistory of

atopy

Durationof disease

(years)

at time of surgery

No. of Recurren

ces PeakIOP

(mmHg)

Durationof

steroid

use (Weeks)

Mainsteroid

used

No. of anti-glaucoma

medications Type of Surgery

MeanClinicalgrade of

VKC

Pre-operative

MeanClinicalgrade of

VKC

Post-operative

P-value

4/M/c Y 4 3 35 9 D 2

RTrabeculectomy

/ MMC

L: 3.934 R: 4.000

L: 1.000 R: 0.932

0.014

5/M/i Y 3

12 31 18 D 3 R & L

Trabeculectomy/ MMC

L: 3.666 R: 4.000

L: 1.000 R: 1.022

0.035

7/M/i Y 4 3 42 7 D 2

LTrabeculectomy

/ MMC

L: 4.000 R: 0.534

L: 1.000 R: 0.534

0.001

7/M/c Y 6 6 34 72 D 3 R

Trabeculectomy/ MMC

L: 3.332 R: 3.668

L: 3.668 R: 0.932

0.001

13/M/c Y 9 10 53 30 D 2 R & L

Trabeculectomy/ MMC

L: 3.668 R: 3.934

L: 0.934 R: 0.934

0.030

14/M/c Y 6 8 38 39 PF 2 L

Trabeculectomy/ MMC

L: 3.268 R: 3.934

L: 0.866 R: 3.868 0.001

Demographics: Age= Presenting Age, M=Male, c= Chinese, i=Indian, m=Malay; Medical history: Y=Yes, N=No; Mainsteroid used: D=Dexamethasone 0.1% Topical, PF= Predforte 1.0% Topical; Clinical grade of VKC: Based on modifiedclinical grading by Bonini et al 8 weeks pre-operatively and duration of post-operative period.


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RISK FACTORS FOR TRABECULECTOMY VKC patients with steroid response requiring

trabeculectomy with MMC were compared with thosetreated medically

This was performed with age and gender-adjustedlogistic regression

Risk factors : Longer duration of steroid use (OR 1.1; 95%CI, 1.0-1.3;

p=0.035) Higher peak IOP (OR1.3; 95%CI, 1.0-1.5; p=0.017)

Greater increase in IOP from baseline (OR 1.3; 95%CI, 1.0-1.5;p=0.011)

Multivariate analysis revealed this to be the most significant risk factor

Other factors eg type of steroid used, type of VKC (ie limbal,tarsal, mixed), corneal involvement or neovascularization were

not found to be significant


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POST-TRABECULECTOMY OUTCOMES

Significant improvement in severity of VKC post-trabeculectomy in all 8 eyes,with reduced dependence on topicalsteroids

Mean clinical grade of improvement 2.1;95% CI, 1.3-3.0; p


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DISCUSSION The risk of corticosteroid-induced glaucoma in Asianeyes with VKC may be higher due to the chronicity of the

disease and the long-term use of topical steroids, as inthe patients in our study

Our study found important risk factors for trabeculectomyin these cases to be longer duration of topical steroiduse, higher peak IOP and greater increase in IOP frombaseline

The limitations of our study are its small numbers andretrospective nature


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DISCUSSION Mitomycin C is an antibiotic-anticancer agent that inhibits

DNA, RNA and protein synthesis and has a long-term effecton cell proliferation. It induces prolonged localised inhibition of Tenons fibroblasts, thus reducing trabeculectomy blebscarring. Its usefulness when applied topically in VKC hasbeen described

In our study, following trabeculectomy with MMC, all eyes sawsignificant improvement in the ocular surface requiringminimal or no use of topical steroids for control of VKCsymptoms

We postulate that the application of 0.02% MMC directly tothe bare sclera in the superior fornix during trabeculectomyinduces significant long-term inhibition of fibroblast andinflammatory cells in the ocular surface, resulting in animprovement in the signs and symptoms of VKC in our

patients


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CONCLUSIONS Prolonged duration of topical steroid use and

greater increase in IOP from baseline are significantrisk factors for severe steroid response requiringtrabeculectomy in Asian patients with severe formsof VKC

Significant improvement in the signs and symptomsof VKC is seen in eyes following trabeculectomywith MMC . This could be related to the after-effectsof MMC on the ocular surface. This supports the

usefulness of MMC in the management of severe,refractory forms of VKC

A Presentation bythe

Singapo re National Eye Center Singapo re National Eye Centre

000064 vkc post trab poster wcc

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