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Year : 1992  |  Volume : 40  |  Issue : 3  |  Page : 79-82

Clinico-immunological aspects of vernal catarrh in hilly terrains of Himachal Pradesh

Department of Ophthalmology and Microbiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Correspondence Address:
Goyal Asha
Good Wood, Shimla (H.P.)
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PMID: 1302230

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Very few immunological studies in vernal catarrh have been conducted in India and abroad, but none in Himachal Pradesh in spite of its high incidence in the State. In the present study 25 patients of vernal catarrh residing at a height ranging between 1000 to 2500 meters above mean sea level have been evaluated. Their immunological status of serum and tears after detailed clinical assessment was studied by single radial immunodiffusion technique of Mancini et al. The values of serum IgA and IgM were significantly higher in patients than in controls. The serum IgE level had no significant difference. The IgG was significantly lower in patients with vernal catarrh. The values of tear IgM, IgE and IgA in these patients were significantly higher than in controls. However, in no case or control group C3C and C4 were detected in tears. The limbal type of vernal catarrh was found to be the most common in this part of the country. No mixed case was seen. Derangement of the immune system in the pathogenesis of vernal catarrh is suggested.

How to cite this article:
Bisht, Asha G, Thakur, Singh T, Sharma, Vijay, GoyalB. Clinico-immunological aspects of vernal catarrh in hilly terrains of Himachal Pradesh. Indian J Ophthalmol 1992;40:79-82

How to cite this URL:
Bisht, Asha G, Thakur, Singh T, Sharma, Vijay, GoyalB. Clinico-immunological aspects of vernal catarrh in hilly terrains of Himachal Pradesh. Indian J Ophthalmol [serial online] 1992 [cited 2024 Feb 22];40:79-82. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1992/40/3/79/24395

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  Introduction Top

Vernal catarrh occurs with the onset of dry, hot weather conditions and affects children and young adults. Since its recognition, various exogenous and endogenous causes have been implicated for its etiopathogenesis. The recent studies, however, point towards an immune mechanism involved in its etiopathogenesis [1].

Very few immunological studies in vernal catarrh have been conducted in India and abroad and the results of those studies have further evoked controversy regarding the complete immunological status of these patients. At the Indira Gandhi Medical College, Shimla, the disease accounts for 1.2% - 1.5% of patients with ocular problems which is quite high when compared to its incidence in the world [2].

Moreover, no such study has been conducted in the hilly areas having height varying from 1000 - 2500 meters from the mean sea level. It was with this in view that the present study has been undertaken.

  Material and methods Top

In the present study, 25 newly clinically diagnosed cases of vernal catarrh, attending the eye out patient department of Indira Gandhi Medical College, Shimla and were not on any treatment were studied. The objectives of the study were explained to all the subjects and written consent obtained. Relevant per­sonal and family history from each patient was recorded. General physical and systemic examination along with local examination of the eye was carried out. The cases were further differentiated as palpebral, limbal and mixed on the basis of clinical findings.

2 ml of blood and tear secretions were collected from clinically diagnosed cases of vernal catarrh. Tear samples were collected by asking the subject to look into a bright source of light. For this purpose a bright beam of light from a slit lamp or an ophthalmoscope depending on patients tolerance to bright light was used. About 300 microlitre sample of tears was collected by glass capillary tubes from the fornices without using any anaesthetic or irritating substance. Simultaneously 25 age and sex matched apparently healthy subjects free from any systemic or other ocular diseases residing in the same en­vironment and geographical conditions were under­taken.

Conjunctival scrapings from the area involved by the disease were obtained with a wet cotton swab and spread over a slide and stained with Giemsa stain to demonstrate eosinophils and granules of mast cells. Fluorescein staining of the cornea was done for any S.P.K. Immunoglobulins were estimated in the serum and tears in the study as well as in the control group by single radial immunodiffusion technique of Manicini et a1 [3]. Tripartigen plates (Hoechst) were used for serum immunoglobulins and low con­centration (LC - partigen) immunodiffusion plates (Hoechst) were used for tear immunoglobulins. Serum and tear complements C3C and C4 levels were estimated by using nor-partigen immunodiffusion plates. Students `t' test was applied to find out the significance of the results.

The incidence of vernal catarrh was calculated on the basis of last five years hospital records. The seasonal variation, if any was recorded.

  Results Top

The present study included 25 patients of vernal catarrh attending the eye O.P.D. in I.G. Medical College, Shimla. In addition 25 age and sex matched controls were also studied. All the cases were residents of hilly areas of the state, the height ranging between 1000 meters to 2500 meters above mean sea level. The age varied from 7 years to 30 years with the mean age of 14.3 years. Duration of symptoms was 1 1/2 years to 4 years. There were 20 males (80 per cent) and 5 females (20 per cent). Most common presenting feature was itching (100 per cent) and was more during the day time. The precipitating factors were dust, wind and hot dry weather (most common). Photophobia was present in 40 per cent and lacrimation in 96 per cent of cases. However, ropy type of discharge was present only in 6 cases (24 per cent). The patients who were already on treatment were not included in the study. Family history of atopy was observed in 3 cases (12 per cent). Visual acuity was found to be normal in 24 cases (96 per cent).

Out of a total of 25 cases, 20 (80 per cent) were of the limbal type and 5 (20 per cent) were of the palpebral type. No mixed case was seen. No patient showed mechanical ptosis, extralid fold, pseudomenbrane formation, concretions and micropan­nus. However, Horner-Tranta's spots were seen in 10 patients (40 per cent). Corneal opacity in 5 (20 per cent), pseudogenontoxin in 1 (4 per cent) and keratoconus in 1 case (4 per cent). SPK, flour-dust appearance and shield shaped ulcers were not observed in any case. Majority of the patients showed eosinophils and basophils with mast cells and eosinophilic granules from the scrapings of the involved conjunctiva.

The serum and tear immunoglobulins in controls and cases are shown in [Table - 1]. The complements C3C and C4 were not detected in tears. The serum complements in controls and subjects are shown in [Table - 2].

The retrospective records of the last five years of the eye out patient department revealed the incidence of vernal catarrh to be 1.2 to 1.5 per cent of all patients attending the eye OPD. However, the incidence of the disease in the paediatric age group was found to be 4.8 to 6.0 per cent. Maximum number of cases were observed during the months of May, June, September and October.

  Discussion Top

Vernal catarrh is known to be a disease of children and young adults and in the present study the age of the patients varied between 7 to 30 years with the mean age of 14.3 years. Its much frequent occurrence during the months of May, June, September and October suggests that some exogenous allergens particularly actinic rays and dust during these months exacerbates the disease.

The duration and chronicity of the disease ranging from one and half years to four years is in conformity with the other studies [4]. The most common presenting feature of itching (100 per cent) supports the dictum "NO ITCHING, NO VERNAL CATARRH", Lacrimation was the other most common presentation and the presence of photophobia in many cases (40 per cent) suggest some constant irritant, possibly present in the environment. Some patients giving history of atopy in the form of nasal allergy supports its allergic nature. Probably its occurrence in May and June is linked to hypersensitivity to pollen dust [4]sub from some local plants to some bacteria or fungi [5] as suggested by other workers. While its high incidence in May, June, September and October may be related to more exposure to actinic rays at high altitude because of clear and sunny weather in this part of the state. Family history of atopy in 12 per cent patients is suggestive of familial tendency. Ropy discharge from the diseased eyes (24 per cent) was not a very common presenting feature probably due to its less fulminant nature in many cases.

Out of total 25 cases of vernal catarrh, 20 (80 per cent) belonged to the limbal type and 5 (20 per cent) to the palpebral type. No mixed case of the disease was observed. There was no statistical significance of immunoglobulin alterations in serum and tears in both the groups when compared with each other, hence were not dealt separately. Absence of eosinophils from the conjunctival scrapings in the present study supports the local hypersensitivity reaction in conjunctiva as held by other workers [6].

In the present study the values of serum IgA, IgM, IgG, IgE [Table - 1] and complements C3C and C4 in controls [Table - 2] are in accordance with the findings of other Indian research workers [7][8][9]. The levels of tear IgA and IgG in controls were well comparable to the controls studied by other workers [10]. However, IgM was not detectable in any of our control sample and it is in conformity with studies by other workers [10][11]. IgE, complements C3C and C4 were not detectable in tears of normal controls, though it was detectable in small amounts by other workers [12][13].

The IgE levels were significantly raised in tears of our study group (p.<25) while in serum the rise was insignificant (p>.05) which suggests that the specific IgE antibodies could be produced local ly [14] and points towards the allergic aetiology. However, C3C and C4 were not detectable in tears of study group.

The IgM levels in the serum (p) as well as in the tears (p) of these patients were significantly raised. This could be because of transudation of this immunoglobulin from plasma into the tears but it cannot be proved because no marker in the serum was used in the present study to show its presence in the tears. However, it requires further elaborate study to prove whether this significant rise of IgM in both serum and tears of these patients has to suggest its role in the pathogenesis of vernal catarrh.

The considerably increased levels of IgA in serum (p) and tears (p) in the present study may point towards the fact that these patients with chronicity and recurrence of the disease show an accompaniment of low grade infection. Allansmith et a1 [15]sub found abundant IgA, forming plasma cells in two of the four patients of vernal catarrh when their abnormal upper tarsal tissue was stained immunofluorescently. These studies [15][16], therefore, emphasize the fact that the external eye can mount a local immune response to antigenic stimulation.

The IgG was significantly lower (p) in patients of vernal catarrh but the insignificant rise of IgG (p 0.05) in tears of these patients along with no detection of complements in tears of controls as well as patients suggest that IgG mediated mechanism may not be playing any significant role in the pathogenesis of vernal catarrh. As the levels of tear IgG did not show any rise in these patients the activation of complements could not take place, C3C and C4 could not be detected.

It is concluded that beside other factors like pollen dust, allergens from local plants, bacteria and fungi as suggested by other workers, there is a definite role of actinic rays in the etiopathogensis of vernal catarrh in hilly terains. Derangement of the immune system in the pathogenesis of vernal catarrh is suggested.

  References Top

Stephen, J.H. Miller. A note book, Parson's disease of the eye: Disease of the conjunctiva, 17th ed (Churchill Livingstone Edinburgh London Melbourne & New York) 1984, 125­  Back to cited text no. 1
Beiglman, M.N. Vernal conjunctivitis. Los Angeles University, South California Press, 1950.  Back to cited text no. 2
Mancini, G.; Carbonara, A.O. and Hormomans, J.F. Im­munological quantitation of antigen by radial immunodiffusion. International journal of Immunochemistry, 1965, 2, 235.  Back to cited text no. 3
Allansmith, M.R. and Baird, Robert, S. Percentage of degranu­lated mast cells in vernal conjunctivitis & giant papillary conjunctivitis associated with contact-lens wear. Am. J. Oph­thalmol. 1981, 91,71.  Back to cited text no. 4
Neumann, E.; Gutmann, M.J.; Blumanlarante, N.; Michaelson, I.C. A review of 400 cases of vernal conjunctivitis. Am. J. Ophthalmol 1959, 47, 166.  Back to cited text no. 5
Alimuddin, M. Vernal conjunctivitis. Br. J. Ophthalmol. 1955, 39, 160.  Back to cited text no. 6
Samuel, A.M.; Despande, U.R. and Singh, B. Immunoglobulins in normal Indian adults. Ind. J. Med. Res, 1970, 58, 56.  Back to cited text no. 7
Sehgal, S. and Aiket, B.K. Serum immunoglobulin in healthy Indians. Indian J. Med. Res, 1970, 58,289.  Back to cited text no. 8
Gupta, R.M.; Gupta, B.M. and Marwah, S.M. Pattern of intestinal parasitic infections & serum IgG and IgM levels in Tibetans & Indians. J. Indian Med. Assoc, 1977, 59, 31.  Back to cited text no. 9
Donshik, P.C.; Ballow, M. Tear immunoglobulins in giant papillary conjunctivitis induced by contact lenses. Am. J. Ophthalmol, 1983, 96, 460.  Back to cited text no. 10
Mc Clellan, Barbara, N. Whitney, C.R. Immunoglobulins in tears. Am. J. Ophthalmol, 1973, 76, 89.  Back to cited text no. 11
Chandler, J.W.; Leder, R.; Kaufman, H.E. and Caldwell, J.R. Quantitative determination of complement & im­munoglobulins in tears and aqueous humour. Invert. Oph­thalmology. 1974, 13, 151.  Back to cited text no. 12
Bluestone, R.; Easty, L.S.; Goldberg et al. Lacrimal im­munoglobulins and complement quantified by counter im­munoelectrophoresis. Br. J. Ophthalmol, 1975, 59, 279.  Back to cited text no. 13
Ballow, M.; Mendel son, L.; Specific Ig of patients with vernal conjunctivitis. J. allergy Clin. Immunol, 1980, 66, 112.  Back to cited text no. 14
Allansmith, M.R.; Sain, G.S.; and Simon, M.A. : Tissue tear and serum IgE concentration in vernal conjunctivitis. Am. J. Ophthalmol, 1976, 81, 506.  Back to cited text no. 15
Selinger, D.S.; Selinger, R.C.; Reed, W.P. Resistance of infection of the external eye : the role of tears. Surv. Ophthalmol, 1974, 24, 33.  Back to cited text no. 16


  [Table - 1], [Table - 2]


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