• Users Online: 1360
  • Home
  • Print this page
  • Email this page

   Table of Contents      
Year : 2013  |  Volume : 61  |  Issue : 8  |  Page : 407-409

Ocular allergy and keratoconus

1 Department of Cornea and Refractive Surgery, Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
2 Department of Cornea and Refractive Surgery, Aditya Jyot Eye Hospital, Mumbai, India
3 Department of Cornea and Refractive Surgery, Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, Australia

Date of Submission04-Jul-2013
Date of Acceptance25-Jul-2013
Date of Web Publication3-Aug-2013

Correspondence Address:
Namrata Sharma
Cornea and Refractive Surgery Services, Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi - 110 029, India

Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.116063

Rights and Permissions

Keratoconus is the most common corneal ectatic disorder, the cause of which is largely unknown. Many factors have been implicated, and the ocular allergy is being one of them. The commonly proposed pathogenesis includes the release of inflammatory mediators due to eye rubbing which may alter the corneal collagen and lead to corneal ectasias. The onset of keratoconus is often early in cases associated with allergy and routine corneal topography may detect subtle forms of keratoconus. These cases may require early keratoplasty and are at an increased risk of having acute corneal hydrops. Surgical outcomes are similar to primary keratoconus cases. However, post-operative epithelial breakdown may be a problem in these cases. Control of allergy and eye rubbing is the best measure to prevent corneal ectasias in cases of ocular allergy.

Keywords: Keratoconus, ocular allergy, vernal keratoconjunctivitis

How to cite this article:
Sharma N, Rao K, Maharana PK, Vajpayee RB. Ocular allergy and keratoconus. Indian J Ophthalmol 2013;61:407-9

How to cite this URL:
Sharma N, Rao K, Maharana PK, Vajpayee RB. Ocular allergy and keratoconus. Indian J Ophthalmol [serial online] 2013 [cited 2022 Aug 14];61:407-9. Available from: https://www.ijo.in/text.asp?2013/61/8/407/116063

Keratoconus (KC) is a clinical term used to describe a condition in which the cornea assumes a conical shape because of thinning and protrusion. [1] The cause of this disease is still unknown. A positive association between KC and many conditions has been suggested and ocular allergy is one of them. [1] The various ocular allergic conditions that have been associated with KC includes vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis and seasonal or perennial allergic keratoconjunctivitis. [1]

This review article attempts to study the association of ocular allergy with KC, and its implications on the management of KC.

  Review of literature Top

Association between ocular allergy and keratoconus

The first reported association between ocular allergy and KC was described by Hilgartner in 1937. [1] The association was controversial with few studies reporting an association ranging from 7 to 35% while others did not show any relationship. [1] However, more recent studies have proved that there is a definite association between allergy and KC. Bawazeer et al., did a case control study and found a positive correlation between atopy, eye rubbing, and KC. [2] The Dundee University Scottish Keratoconus study was a prospective observational study of 200 consecutive patients presenting with KC. [3] They found atopic diseases including asthma in 23%, eczema in 14%, and hay fever in 30% of the KC patients. A study from India by Agrawal et al., evaluated 274 patients of KC and revealed a higher prevalence of allergy in these patients. [4] History of skin allergy, symptomatic ocular allergy, and asthma was seen in 26.6, 24.4, and 11.3% of patient's, respectively. [4]

Pathogenesis of ocular allergy and KC

KC is characterized by progressive stromal thinning as a result of increased expression of lysosomal and proteolytic enzymes, decreased concentration of protease inhibitors, which result in altered collagen configuration. [5],[6] In allergic conjunctivitis when specific allergens are re-introduced into the body through the conjunctiva it reacts with the allergen specific IgE on the surface of mast cells or basophils, releasing vasoactive mediators. These mediators include inflammatory molecules like histamine, proteases, tumor necrosis factor (TNF) -alpha, and interleukin (IL). [1],[3],[4],[5],[6],[8] Increased proteases, protease activity, and inflammatory molecules in the tears have been found to be relevant in the pathogenesis of KC. It has been proven that eye rubbing increases the level of tear matrix metalloproteinases (MMP)-13, IL-6, and TNF- alpha even in normal subjects. [5],[6] It has been hypothesized that this increase in protease activity may be further exacerbated during forceful eye rubbing seen in patients with allergic conjunctivitis, contributing to the development and progression of KC.

Role of early topography in ocular allergy

Since allergic disorders may be associated with early onset of KC, routine topography is indicated in such cases. Totan et al., studied the incidence of KC in VKC and found KC in 26.8% by quantitative evaluation of videokeratography (VKG) maps. [7] There was an increased incidence of KC with male gender, long standing disease, mixed/palpebral form, and advanced cornea lesions. They concluded that the higher incidence of KC in their study was due to early detection of mild KC with topography, stressing its importance in VKC patients. Léoni-Mesplié et al., studied the epidemiological aspects of KC in 49 children and compared these with 167 adult patients. [8] They found that allergy as well as eye rubbing are more in children compared to adults (allergy; 67.3 versus 47.3% in adults and eye rubbing; 91.8 versus 70% in adults). The authors recommend that corneal topography should be performed routinely in all young, allergic boys with the history of eye rubbing and recent-onset corneal astigmatism.

Role of ocular allergy in progression of KC

The effect of allergy on KC progression is controversial. Study by Lapid-Gortzak et al., evaluated the VKG findings in children with VKC (n = 40) versus those of healthy children (n = 36) and found that VKC patients have more abnormal corneal topographic patterns than non-VKC controls. [9] Barreto Jr et al., compared the slit-scanning topographic (SST) pattern of eyes with VKC (n =50) and normal eyes (54) and found that patients with VKC have more abnormal corneal SST patterns than controls. [10] A recent study by Taneja et al., evaluated KC progression in patients with VKC (22 eyes) using scanning slit topography and found that the rate of progression is not affected by the clinical course of VKC. [11]

Although allergy may not hasten KC progression, it definitely increases the chances of complications such as hydrops. In a study by Sharma et al., risk factors for keratoplasty and development of acute corneal hydrops in 120 consecutive KC patients were evaluated. [12] It was found that the patients of KC who had VKC required corneal transplant surgery earlier as compared to primary KC cases. In addition patients with younger age at onset, history of eye rubbing, and atopy had higher risk for developing corneal hydrops. [12]

Surgical outcome in cases of ocular allergy and KC

Egrilmez et al., evaluated the effect of VKC on clinical outcomes of penetrating keratoplasty (PKP) in 33 eyes of KC. [13] They found that the clinical outcomes of PKP in eyes with KC and VKC is comparable to that in eyes with KC alone. However, complications such as loose sutures and steroid-induced cataracts were more common in cases with KC who had VKC. Wagoner et al., found that the graft survival, postoperative complications, and visual outcomes are comparable after PKP for KC in eyes with (n = 80) or without VKC (n = 384). [14] Thomas et al., compared the prevalence of endothelial rejection episodes and the probability of graft survival after initial and repeat PKP in patients with KC with (n = 66) and without (n = 102) atopy and found no statistically significant difference in the prevalence of endothelial graft rejection episodes or probability of graft survival. [15] Thus, it can be concluded that even though the final outcome may not differ after keratoplasty in cases of KC with or without ocular allergy, close follow up is required in the postoperative period to detect epithelial breakdown and steroid induced complications.

  Personal experience Top

KC accounts for almost 90% of the lamellar keratoplasties and 5-10% of PKP are done at our center. VKC is the commonest type of association we find in our cases [Figure 1] and [Figure 2]. These cases usually present early (in fact we have seen advanced KC cases at the age of 8 years) and show rapid progression. Patients with concomitant VKC may require early keratoplasty in cases of KC. Moreover, history of eye rubbing, VKC, and atopy increase the risk for developing acute corneal hydrops. [12] Post-operative course is also quite challenging in these cases. Chances of postoperative prolonged inflammation, epithelial breakdown and rapid healing with early loosening of sutures are commonly observed in these cases. Eye rubbing is the leading factor for early onset and rapid progression, hence all the cases of atopy or VKC must be advised to avoid eye rubbing. Prior to the surgery it must be ensured that the inflammation is controlled.
Figure 1: Case of vernal keratoconjunctivitis with keratoconus having giant papillary conjunctivitis

Click here to view
Figure 2: Same case as in Figure 1 with keratoconus

Click here to view

  Discussion Top

Ocular allergy is one of the important risk factors for KC. Subtle cases are unmasked on topography and hence all cases with ocular allergy should routinely be subjected to these investigations. Eye rubbing precipitates the onset and may also exacerbate the progression of KC; hence the patients should be advised to avoid eye rubbing. These cases are at an increased risk of complications such as acute corneal hydrops and may require early keratoplasty. The surgical outcome in cases of ocular allergy with KC is similar to the primary cases of KC, but a close follow up is required to avoid complications related to epithelial healing or steroid use.

  Conclusion Top

To conclude ocular allergy has an important role in pathogenesis, disease progression, and the treatment outcome in cases of KC. Although a number of studies have proven this over the past decades, yet randomized controlled clinical trials on larger number of cases with longer follow up is required. Control of inflammation and avoidance of eye rubbing may offer the best means to prevent KC in these cases.

  References Top

Krachmer JH, Feder RS, Belin MW. Keratoconus and related noninflammatory corneal thinning disorders. Surv Ophthalmol 1984;28:293-322.  Back to cited text no. 1
Bawazeer AM, Hodge WG, Lorimer B. Atopy and keratoconus: A multivariate analysis. Br J Ophthalmol 2000;84:834-6.  Back to cited text no. 2
Weed KH, MacEwen CJ, Giles T, Low J, McGhee CN. The Dundee University Scottish Keratoconus study: Demographics, corneal signs, associated diseases, and eye rubbing. Eye (Lond) 2008;22:534-41.  Back to cited text no. 3
Agrawal VB. Characteristics of keratoconus patients at a tertiary eye center in India. J Ophthalmic Vis Res 2011;6:87-91.  Back to cited text no. 4
  Medknow Journal  
Balasubramanian SA, Mohan S, Pye DC, Willcox MD. Proteases, proteolysis and inflammatory molecules in the tears of people with keratoconus. Acta Ophthalmol 2012;90:e303-9.  Back to cited text no. 5
Balasubramanian SA, Pye DC, Willcox MD. Effects of eye rubbing on the levels of protease, protease activity and cytokines in tears: Relevance in keratoconus. Clin Exp Optom 2013;96:214-8.  Back to cited text no. 6
Totan Y, Hepºen IF, Cekiç O, Gündüz A, Aydin E. Incidence of keratoconus in subjects with vernal keratoconjunctivitis: A videokeratographic study. Ophthalmology 2001;108:824-7.  Back to cited text no. 7
Léoni-Mesplié S, Mortemousque B, Mesplié N, Touboul D, Praud D, Malet F, et al. Epidemiological aspects of keratoconus in children. J Fr Ophtalmol 2012;35:776-85.  Back to cited text no. 8
Lapid-Gortzak R, Rosen S, Weitzman S, Lifshitz T. Videokeratography findings in children with vernal keratoconjunctivitis versus those of healthy children. Ophthalmology 2002;109:2018-23.  Back to cited text no. 9
Barreto J Jr, Netto MV, Santo RM, José NK, Bechara SJ. Slit-scanning topography in vernal keratoconjunctivitis. Am J Ophthalmol 2007;143:250-4.  Back to cited text no. 10
Taneja M, Ashar JN, Mathur A, Vaddavalli PK, Rathi V, Sangwan V, et al. Measure of keratoconus progression in patients with vernal keratoconjunctivitis using scanning slit topography. Cont Lens Anterior Eye 2013;36:41-4.  Back to cited text no. 11
Sharma R, Titiyal JS, Prakash G, Sharma N, Tandon R, Vajpayee RB. Clinical profile and risk factors for keratoplasty and development of hydrops in north Indian patients with keratoconus. Cornea 2009;28:367-70.  Back to cited text no. 12
Egrilmez S, Sahin S, Yagci A. The effect of vernal keratoconjunctivitis on clinical outcomes of penetrating keratoplasty for keratoconus. Can J Ophthalmol 2004;39:772-7.  Back to cited text no. 13
Wagoner MD, Ba-Abbad R. King Khaled Eye Specialist Hospital Cornea Transplant Study Group. Penetrating keratoplasty for keratoconus with or without vernal keratoconjunctivitis. Cornea 2009;28:14-8.  Back to cited text no. 14
Thomas JK, Guel DA, Thomas TS, Cavanagh HD. The role of atopy in corneal graft survival in keratoconus. Cornea 2011;30:1088-97.  Back to cited text no. 15


  [Figure 1], [Figure 2]

This article has been cited by
1 Pediatric Crosslinking: Current Protocols and Approach
Júlia Polido, Maria Emília dos Xavier Santos Araújo, João G. Alexander, Thiago Cabral, Renato Ambrósio, Denise Freitas
Ophthalmology and Therapy. 2022;
[Pubmed] | [DOI]
2 Childhood Corneal Cross-Linking: Follow-Up to Document Progression to Intervene
Juan-Carlos Abad
Cornea. 2022; Publish Ah
[Pubmed] | [DOI]
3 A Review of Emerging Tear Proteomics Research on the Ocular Surface in Ocular Allergy
Esrin Aydin, Poshmaal Dhar, Moneisha Gokhale, Luke Chong, Serap Azizoglu, Cenk Suphioglu
Biology. 2022; 11(2): 312
[Pubmed] | [DOI]
4 Corneal Epithelium Asymmetry in Children With Atopy: The Effect of Hand Dominance
Tomás Loureiro, Sandra Rodrigues-Barros, Ana Rita Carreira, Filipe Gouveia-Moraes, Pedro Carreira, Ana Vide Escada, Paul Campos, Inês Machado, Nuno Campos, Timothy J Archer, Dan Z Reinstein, Renato Ambrósio
Clinical Ophthalmology. 2022; Volume 16: 2453
[Pubmed] | [DOI]
5 Characteristics of pediatric keratoconus and the role of corneal topography in early diagnosis: A prospective study
Sujatha Mohan, Manideepa Banerjee, Sriram Annavajjhala
TNOA Journal of Ophthalmic Science and Research. 2022; 60(1): 15
[Pubmed] | [DOI]
6 Changes in Anterior and Posterior Corneal Elevation in Patients With Allergic Conjunctivitis
Qian Wang, Fei Yu, Ziqing Feng, Weihua Li, Naiyang Li, Xinyue Du, Xuan Zhao, Saiqun Li, Jin Yuan
Frontiers in Medicine. 2021; 8
[Pubmed] | [DOI]
7 Characteristics of Keratoconus Patients in Jordan: Hospital-Based Population
Noor Alqudah, Hisham Jammal, Yousef Khader, Wedad Al-dolat, Sarah Alshamarti, Zaki Shannak
Clinical Ophthalmology. 2021; Volume 15: 881
[Pubmed] | [DOI]
8 Nationwide epidemiological approach to identify associations between keratoconus and immune-mediated diseases
Janneau L J Claessens, Daniel A Godefrooij, Gerko Vink, Laurence E Frank, Robert P L Wisse
British Journal of Ophthalmology. 2021; : bjophthalm
[Pubmed] | [DOI]
9 The prevalence of keratoconus in children with allergic eye disease in an Egyptian population
Alyaa Saeed Ahmed, Mohamed-Sameh H El-Agha, Mahmoud Osama Khaled, Shireen Mostafa Shousha
European Journal of Ophthalmology. 2021; 31(4): 1571
[Pubmed] | [DOI]
10 Determination of copper by AAS in tear fluid of patients with keratoconus
Gianfranco Corbini, Elena Dreassi, Luisa Chiasserini, Matteo Maria Girolamo, Pierfrancesco Mellace
Analytical Biochemistry. 2021; 623: 114174
[Pubmed] | [DOI]
11 Pediatric Keratoconus: Topographic, Biomechanical and Aberrometric Characteristics
Yogita Gupta, Namrata Sharma, Prafulla K. Maharana, Rohit Saxena, Rajesh Sinha, Tushar Agarwal, Vishal Jhanji, Jeewan S. Titiyal
American Journal of Ophthalmology. 2021; 225: 69
[Pubmed] | [DOI]
12 Management of corneal complications in vernal keratoconjunctivitis: A review
Sepehr Feizi, Mohammad Ali Javadi, Mohammadhasan Alemzadeh-Ansari, Amir Arabi, Toktam Shahraki, Ahmad Kheirkhah
The Ocular Surface. 2021; 19: 282
[Pubmed] | [DOI]
13 Corneal Scheimpflug topography values to distinguish between normal eyes, ocular allergy, and keratoconus in children
Matheus Ivan Schmitz Vieira, Alessandro Adad Jammal, Carlos Eduardo Leite Arieta, Monica Alves, Jose Paulo Cabral de Vasconcellos
Scientific Reports. 2021; 11(1)
[Pubmed] | [DOI]
14 Vernal keratoconjunctivitis and keratoconus
Denise Wajnsztajn, Abraham Solomon
Current Opinion in Allergy & Clinical Immunology. 2021; 21(5): 507
[Pubmed] | [DOI]
15 Pharmacotherapeutic management of atopic keratoconjunctivitis
Ibtesham T Hossain, Priyanka Sanghi, Bita Manzouri
Expert Opinion on Pharmacotherapy. 2020; 21(14): 1761
[Pubmed] | [DOI]
16 Topographic properties of the cornea in welders
Amir Asharlous, Hassan Hashemi, Abbasali Yekta, Mohamadreza Aghamirsalim, Hadi Ostadimoghaddam, Hamid Gharaee, Sara Sardari, Mehdi Khabazkhoob
European Journal of Ophthalmology. 2020; : 1120672120
[Pubmed] | [DOI]
17 Assessment of the mechanical forces applied during eye rubbing
Farhad Hafezi, Nikki L. Hafezi, Bojan Pajic, Francesca Gilardoni, J. Bradley Randleman, Jose Alvaro P. Gomes, Léonard Kollros, Mark Hillen, Emilio A. Torres-Netto
BMC Ophthalmology. 2020; 20(1)
[Pubmed] | [DOI]

Transepithelial Accelerated Corneal Collagen Cross-Linking: Two-Year Results

Ana Maria Cunha, Tiago Sardinha, Luís Torrão, Raúl Moreira, Fernando Falcão-Reis, João Pinheiro-Costa
Clinical Ophthalmology. 2020; Volume 14: 2329
[Pubmed] | [DOI]
19 Incidence of Keratoconus and Its Association with Systemic Comorbid Conditions: A Nationwide Cohort Study from South Korea
Jong Youn Moon, Jesang Lee, Yoon Hyung Park, Eun-Cheol Park, Si Hyung Lee
Journal of Ophthalmology. 2020; 2020: 1
[Pubmed] | [DOI]
20 Unique corneal tomography features of allergic eye disease identified by OCT imaging and artificial intelligence
Himanshu Matalia, Jyoti Matalia, Anchana Pisharody, Yash Patel, Nandini Chinnappaiah, Marcella Salomao, Renato Ambrosio, Abhijit Sinha Roy
Journal of Biophotonics. 2020; 13(10)
[Pubmed] | [DOI]
21 Epidemiological Association Between Systemic Diseases and Keratoconus in a Korean Population: A 10-Year Nationwide Cohort Study
Hyo Kyung Lee, Eun Hye Jung, Bum-Joo Cho
Cornea. 2020; 39(3): 348
[Pubmed] | [DOI]
22 Relevance of IgE, allergy and eye rubbing in the pathogenesis and management of Keratoconus
Prerna Ahuja, Zelda Dadachanji, Rohit Shetty, SowmyaArudi Nagarajan, Pooja Khamar, Swaminathan Sethu, Sharon D'Souza
Indian Journal of Ophthalmology. 2020; 68(10): 2067
[Pubmed] | [DOI]
23 Thermo-cauterization and amniotic membrane grafting for extensive hydrops in a child with vernal keratoconjunctivitis
Rashmi Mittal, Hitendra Ahooja
Indian Journal of Ophthalmology. 2020; 68(4): 644
[Pubmed] | [DOI]
24 Pathogenesis and complications of chronic eye rubbing in ocular allergy
Hadas Ben-Eli, Nir Erdinest, Abraham Solomon
Current Opinion in Allergy & Clinical Immunology. 2019; 19(5): 526
[Pubmed] | [DOI]
25 Conjunctivitis Preferred Practice Pattern®
Divya M. Varu, Michelle K. Rhee, Esen K. Akpek, Guillermo Amescua, Marjan Farid, Francisco J. Garcia-Ferrer, Amy Lin, David C. Musch, Francis S. Mah, Steven P. Dunn
Ophthalmology. 2019; 126(1): P94
[Pubmed] | [DOI]
26 Snake-like Chromatin Cell Protein as an Indicator of Chronic Eye Rubbing in Patients with Keratoconus and Allergic Conjunctivitis
Maria A Henriquez, Nadia Canorio, Carmen Maldonado, Mirel Rincon, Luis Izquierdo Jr
International Journal of Keratoconus and Ectatic Corneal Diseases. 2018; 7(2): 91
[Pubmed] | [DOI]
27 Allergen-specific exposure associated with high immunoglobulin E and eye rubbing predisposes to progression of keratoconus
Rohit Shetty, Shraddha Sureka, Pallak Kusumgar, Swaminathan Sethu, Kanchan Sainani
Indian Journal of Ophthalmology. 2017; 65(5): 399
[Pubmed] | [DOI]
28 Mechanical Modeling of a Keratoconic Cornea
Jean Marc Perone, Jean Baptiste Conart, Pierre-Jean Bertaux, Nicolas Sujet-Perone, Nadia Ouamara, Maxime Sot, Jean Jacques Henry
Cornea. 2017; 36(10): 1263
[Pubmed] | [DOI]
29 Evolution on Keratoconus and Corneal Ectatic Diseases: Paradigms and Paradoxes
Marcella Salomão, Bernardo Lopes, Fernando Faria-Correia
International Journal of Keratoconus and Ectatic Corneal Diseases. 2016; 5(3): 0
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Review of literature
Personal experience
Article Figures

 Article Access Statistics
    PDF Downloaded709    
    Comments [Add]    
    Cited by others 29    

Recommend this journal