210 Pak J Ophthalmol. 2022, Vol. 38 (3): 210-215 

Original Article 

Using Survey Scale to Assess the Reduction in 
Intensity of Vernal Keratoconjunctivitis Symptoms 

after Administration of Drugs in Tertiary Care 
Hospital 

 
Poombal

1
, Rashad Qamar Rao

2
, Waseem Sajjad

3
, Wamiq Mehmood

4
, Aiman

5 

1-4
Nishtar Medical University &Hospital, Multan, 

5
Quaid-e-Azam Medical College, Bahawalpur 

 

ABSTRACT 
Purpose: To establish the practicality of survey scale in estimating baseline severity at the time of diagnosis and 

resolution of Vernal keratoconjunctivitis (VKC) symptoms after topical medication 

Study Design: Longitudinal survey design  

Place and Duration of Study: Ophthalmology department of Nishtar Medical Hospital, Multan from June 2021 to 
November 2021 

Methods: A total of 267 VKC (vernal keratoconjunctivitis) patients' data was filled in on preformed Google forms. 
Improvement in symptoms after follow-ups was recorded on it. Chi-squared test and Kruskal-Wallis test were 
employed to determine the statistical significance of the variables. 

Results: There were 52.4% females and mean age of the patients was 29.52 ± 18.39 years. There was 
preponderance of patients falling under 20 years of age. At baseline, 63.3% patients were on topical steroids, 
while 5.6% of patients were using steroids at the second follow-up visit. The mean interval between patients’ visits 
to the hospital was 7.64 ± 2.086 weeks. Nonparametric Kruskal-Wallis test was used to calculate the difference in 
means of radial point scale scores at the baseline examination (4.47 ± 2.321) and second follow-up (1.31 ± 1.615) 
visits. Z-score value was 15.266 with a significance of 0.001. For patient satisfaction and resolution of symptoms 
at the second follow-up visit, Chi-square values were 164.75 and 119.55, respectively, with a significance of 0.001 
in each case. 

Conclusion: The survey scale aided in quantifying disease symptoms, which can be useful in prescribing and 

adjusting the medications’ dosage easier.  

Key words: Vernal keratoconjunctivitis, Antihistamines, Steroids, Cyclosporine 
 
How to Cite this Article:  Poombal, Rao RQ, Sajjad W, Mehmood W, Aiman. Using Survey Scale to Assess the 
Reduction in Intensity of Vernal Keratoconjunctivitis Symptoms after Administration of Drugs in Tertiary Care 
Hospital. Pak J Ophthalmol. 2022, 38 (3): 210-215. 

Doi: 10.36351/pjo.v38i3.1410 
 

 
 

Correspondence: Wamiq Mehmood 

Nishtar Medical University &Hospital, Multan 

Email: wamiqhassan312@gmail.com 
 
 

Received: April 26, 2022 

Accepted: June 6, 2022 

 
INTRODUCTION 

Vernal keratoconjunctivitis is a bilateral cicatricial 

inflammatory disease of the ocular surface. People 

living in dry, sunny climates such as the 

Mediterranean, Sub-Saharan Africa, the Middle East, 

India, and Pakistan are more prone to it. It commonly 

occurs in younger age groups with male 

predominance, which is thought to be caused by 

altered levels of circulating androgens and oestrogens.
1
 

 In temperate climates VKC occurs seasonally, 

while hot humid weather keeps high load of airborne 

allergens thus leading to more severe symptoms in the 

patients.
2
 



Reduction in Intensity of Vernal Keratoconjunctivitis Symptoms  

Pak J Ophthalmol. 2022, Vol. 38 (3): 210-215 211 

 Risk factors for VKC include age, males, close 

animal contact, personal systemic allergy history, and 

dust exposure.
3
 It is a severe form of recurrent allergic 

conjunctivitis involving both IgE and cell mediated 

immune mechanisms. Initially it was thought to be 

solely type I hypersensitivity mediated by mast cell 

activation. However, type IV hypersensitivity reaction 

occurs with T-helper 2 (Th2) cell type. Th2 cytokines 

inhibit matrix metalloproteinases (MMPs) which result 

in conjunctival collagen build-up.
4
 

 School-going children are mostly affected and 

ocular itching affects their attendance and social 

performance negatively.
5
 

 Multi-morbidities are the term coined for the 

conditions that share common IgE immune mediation. 

Allergic asthma, allergic rhinitis, rhino conjunctivitis, 

atopic dermatitis, vernal keratoconjunctivitis, chronic 

rhinosinusitis with nasal polyps, food allergies, and 

allergic bronchopulmonary aspergillosis.
6
 A patient 

with VKC might have one of these conditions as well. 

 The disease has been classified into three types: 

the palpebral VKC, which presents with giant papillae 

on the tarsal conjunctiva of the lids; the limbal VKC, 

which has Horner-Trantas dots at the limbus; and the 

mixed VKC, which has characteristics of both the 

types. The terms given to them are palpebral, limbal, 

and mixed, respectively.
7
 

 Although VKC is most of the time diagnosed 

using an ophthalmologic examination, some studies 

have been conducted where conjunctival scraping and 

tear cytology reveal leucocytosis with an eosinophilic 

predominance.
8
 Vernal keratoconjunctivitis in 

paediatric patients has led to ocular surface 

remodelling due to constant itching. Complications 

like corneal erosions, shield ulcers and scars. Despite 

being self-limiting condition, these changes in cornea 

are sight threatening and require therapeutic approach 

which will cut off inflammatory cascade causing 

histamine wave.
9
 A lesser-known complication is 

keratoconus which occurs due to corneal epithelium 

rubbing resulting in apical protrusion like state.
10

 

 Although data is available regarding effects of 

different drugs used for VKC, we have used a survey 

scale to assess the reduction in Intensity of Vernal 

Keratoconjunctivitis Symptoms after administration of 

drugs in tertiary care hospital. There is scarcity of such 

surveys from Pakistan which led us to do this research. 

 

METHODS 

This study was conducted at Nishtar Medical Hospital, 

affiliated with Nishtar Medical University, Multan. 

The duration of study was from June 2021 to 

November 2021. Informed consent was obtained from 

all the participants and their parents, in case of minors. 

Non-probability consecutive sampling technique was 

employed for the enrolment of patients. Sample size 

was calculated according to the following formula: 

S = Z
2
 p (1-p)/M

2
 

S is the sample size  

‘z’ is z score its value is 1.96 

‘p’ is the population proportion assumed to be 50% or 

0.5 

‘m’ is the margin of error that is taken 6% or 0.06 

S = (1.96)
2
 (0.5) (1 – 0.5)/(0.06)

2
 = 266.7 = 267 

 Inclusion criteria was bilateral disease clinically 

diagnosed by an ophthalmologist. Exclusion criteria 

was patients already on topical steroids, pregnant 

females, or suffering from any other ocular infectious 

or inflammatory pathology. Patients with glaucoma or 

diabetes or having a family history of either of the two 

were also not kept in the study. Anyone who did not 

show up on follow-up visits was not counted when 

considering attrition. 

 The ethical board of the hospital reviewed and 

allowed the commencement of this research. Diagnosis 

was established based on comprehensive history and 

clinical examination. History of any other skin, nasal, 

or respiratory allergies was considered. Patients or 

parents of minors were asked about symptoms of 

itching, redness of conjunctiva, photophobia, and 

discharge. A thorough slit lamp examination was done 

to look for papillae, Trantas spots, and the severity of 

redness. Fundus of the patient was also examined. IOP 

was checked using Perkin Tonometer on 1st and 2nd 

follow-ups if topical steroids were prescribed. 

 A radial point scale with description of numeric 

points was developed whereby clinical presentations 

of itching, redness of conjunctiva and photophobia 

were used to calculate the score. Ophthalmologists 

calculated the score on examination of patients’ first 

and follow up visits. The score helped estimate the 

severity of disease and help initiate and modify 

medical therapy. The scale was devised with the help 

of four ophthalmologists. It was made in English, but 

the doctors explained it to the patient or underage



Wamiq Mehmood, et al 

212 Pak J Ophthalmol. 2022, Vol. 38 (3): 210-215 

patient’s parents in Urdu. 

 For each end point, "severe" meant 3 points, 

"moderate" earned 2 points, and "mild" was equal to 1 

point. 

 Score of 3 was given in case of constant itching, 
score of 2 in case of frequent itching (present 50% 

of time), score of 1 if occasional episode of severe 

itching, score of 0 if no itching. 

 Score of 3, if vasodilation of all vessels on bulbar 
conjunctiva, score of 2 if many vessels were 

dilated, score of 1 was given in case of several 

vessels. If no manifestation of hyperaemia on 

bulbar conjunctiva, then score 0 was awarded. 

 Score of 3 in alarming photophobia (present when 
dark glasses worn). Score 2 for moderate 

photophobia (requiring dark glasses). Score 1 was 

given in case of mild photophobia (present only in 

daylight). If no photophobia then score was given 

0. 

 All the data was entered into a pre-designed 

Google form. Data was analysed using SPSS version 

28.0. Frequencies and percentages were computed for 

categorical variables like gender and age. Mean ± 

standard deviation was computed for numeric 

variables like age, gender, types of conjunctivitis, 

symptoms at baseline visit, resolution of symptoms at 

consecutive follow-ups, and patient satisfaction. Mean 

and standard deviation were calculated for age and 

radial point scale scores at baseline, first follow-up, 

and second follow-up. Mean and standard deviation 

were also calculated for the intervals between the 

baseline examination and the first and second follow-

up visits. 

 Non-parametric Kruskal-Wallis test was used to 

calculate the difference in means of radial point scale 

scores at baseline and second follow-up visits. The ‘p’ 

value of 0.05 was considered statistically significant. 

 For patient satisfaction and resolution of 

symptoms at the second follow-up visit, the Chi-

square test was used with a p-value of less than 0.05. 

 
RESULTS 

In our study, total of 267 patients were included. For 

age distribution, see Table 1. There were 103 (38.6%) 

under 20 years of age. Age range was 3 to 64 years. 

 Female-to-male ratio was1.102:1. We had 127/267 

male patients as compared 140/267 female patients. 

Mean age of males was 29.56 ± 21.265 and mean age 

of females was 29.48 ± 15.407. Palpebral form of 

VKC was the most dominant type, which accounted 

for 71.5% versus Limbal VKC 12.7% and Mixed VKC 

in 15.7%. 

 

 
 

Figure 1:  Distribution of VKC patients among age groups. 

 
 With the results from radial point scale, 249 

(93.3%) patients were satisfied while 18 (6.7%) 

patients were not satisfied at the second follow-up 

visit. In 239 cases (89.5%) cases, VKC was controlled 

at the second follow-up visit. However, in 28 (10.5%) 

patients, VKC was not controlled at the second follow-

up visit. Radial point scale mean scores and standard 

deviation are shown in Table 1. 

 
Table 1:  Survey scale score. 
 

 Mean 
Std. 

Deviation 

Survey Scale Score baseline 4.47 2.321 

Survey Scale Score first follow up 2.79 2.122 

Survey Scale Score Second follow up 1.31 1.615 

Disease control at 3rd follow up 1.10 .307 

 
 Table 2 shows the drug regimen at baseline visit 

and at second follow-up visit along with the dosage of 

drugs prescribed. 

 Non-parametric Kruskal-Wallis one way analysis 

of variance was used to calculate the difference in 

means of radial point scale scores at baseline 

examination and second follow-up visits. Z score 

value was 15.266 with significance of 0.001. 

 For patient’s satisfaction at the second follow-up 

visit, Chi-square test was used. The calculated value of 

chi-square was 164.750 with a significance value of 

0.001. For disease control at second follow-up visit, 



Reduction in Intensity of Vernal Keratoconjunctivitis Symptoms  

Pak J Ophthalmol. 2022, Vol. 38 (3): 210-215 213 

chi-square value was 119.550 with a significance 

value of 0.001. 

 
Table 2:  Drug regimen at baseline visit and 2

nd
 follow-up. 

 

Drug Regimen 
Baseline 

Visit 

Second 

follow-up 

(0) No Drugs 0 104 (39%) 

(1) Olopatadine
a
 twice per day 76 (28.5%) 119 (44.6%) 

(2) 1 + Cyclosporine
b
 twice 

per day 
22 (8.2%) 29 (10.9%) 

(3) 1+ Fluorometholone
d
 four 

times per day 
148 (55.4%) 10 (3.7%) 

(4) 3 + Oral Desloratadine
e
 

once per day  
21 (7.9%) 5 (1.9%) 

 

Key 
a = Olopatadine Eye Drops 0.2% 

b = Cyclosporine Eye Drops 0.05% 

d = Flouromethalone 0.25% Eye Drops 

e = Desloratadine Tablet 5 mg or Desloratadine Syrup 0.5 mg/ml 

 
DISCUSSION 

The predominance of the patients who presented to us 

in this study were residents of South Punjab, and some 

of the cases were from Baluchistan, interior Sindh as 

well, and a few from Khyber Pakhtunkhwa. 

 In this study we assessed the use of different 

medications used for VKC. Common topical 

medications prescribed are antihistamines such as 

olopatadine and immunosuppressants like ciclosporin, 

but steroids are needed in cases of flare ups or resistant 

cases.
11

 

 Ciclosporin can be used for as long as 12 months 

with better efficacy and safety in paediatric patients.
12

 

Laboratory data, vital signs, slit lamp examination, 

best-corrected distance visual acuity, and intraocular 

pressure raised no safety concerns. However, patients 

should be instructed to protect their eyes against 

sunlight.
13

 

 Supratarsal injection of triamcinolone are also 

used for severe vernal keratoconjunctivitis in 

children.
14

 There is a steroid misuse in the rural 

population, inciting a health crisis. Misused topical 

steroids are into: highly potent drugs (dexamethasone, 

betamethasone), B-moderate (prednisolone), C-weak 

(loteprednol, fluorometholone).
15

 A fortnightly follow-

up for visual assessment and IOP measurement is 

crucial to rule out steroid responders. The steroid 

treatment acts as a domino effect, contributing to a rise 

in IOP and glaucomatous optic disc damage, and 

eventually blindness.
16

 

 Recently, some trials have been conducted 

showing remarkable success with omalizumab.
17

 Brief 

time duration of anti-IgE therapy is effective for 

steroid refractory VKC patients. It has opened new 

horizons for immune pharmacology.
18

 

 Our study had a slight female majority as 

compared to other studies done on VKC.
1,4,19,20,21

 It 

could be because there are more females in the general 

population. However, our findings that most patients 

with VKC belong to the prepubescent/teen age group 

were consistent with numerous studies.
7,20,21

 Our 

study's mean age was 29 years, which was higher than 

that of previous studies. For instance, a retrospective 

study done by Nagpal et al in a tertiary care hospital 

for 6 months, reported the highest incidence of VKC 

occurred in the age group of 11 – 15 years. 

 Palpebral form was the most frequent type found 

in our research, consistent with the observational study 

by Irfan et al.
7
 

 Very few studies probed into the devising of a 

clinical grading score system. To mention Jamil AZ 

and co-authors' study on the sliding scale to investigate 

the severity of symptoms for management of the 

patient with allergic conjunctivitis. A scale was printed 

and given to the patient to be used by both the doctor 

and the patient to estimate severity, which aided in the 

modification of the drug regimen. This caused 

minimal use of medicines and less frequent follow-up 

visits to the hospital, hence saving time and money of 

the patients.
22

 Our study had online forms on cell 

phones that were only filled out by ophthalmologists 

in OPD. The similarity among both studies was that 

neither studied the efficacy of the drugs, resolution of 

symptoms, or patient satisfaction. 

 Earlier, A.M. Zicari et al tried to grade Vernal 

keratoconjunctivitis by devising the criteria based on 

presence of major symptoms (and how many) and 

minor symptoms. It was not uniform or agile to be 

used in paediatricpatients.
23

Pacci et al used serum ECP 

(eosinophil cationic protein) as a useful marker of 

disease activity in tarsal and mixed forms. Despite 

being subjective, it resulted in findings merging with 

allergic conjunctivitis.
24

 

 We need a reliable and valid scoring system which 

suits both practitioner and patient alike. Something, 

which benefits paediatricians in evaluation of ocular 

involvement during baseline diagnosis and looking 

through course of this disease and treating it. 

Limitations of our study was that only 3 symptoms 



Wamiq Mehmood, et al 

214 Pak J Ophthalmol. 2022, Vol. 38 (3): 210-215 

were used in the study, which did not include 

conjunctival discharge. The study will not be feasible 

in peripheral non-urban centres that do not have access 

to stable internet facilities. Moreover, a flare up in 

symptoms due to seasonal variation was not 

considered. 

 
CONCLUSION 

The survey scale made quantifying the severity of 

clinical features of VKC and the progression or 

regression of the disease, along with the patient’s 

contentment during subsequent visits, computationally 

convenient. Drug regimens were modified using 

disease estimations from this scale. 

 
Conflict of Interest: Authors declared no conflict 
of interest. 

 
Ethical Approval 

The study was approved by the Institutional review 

board/Ethical review board (Ref. No. 4121). 

 
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Authors’ Designation and Contribution 

Poombal; House Officer: Design, Data analysis, 

Statistical analysis. 

Rashad Qamar Rao; Professor: Concepts, 

Manuscript review. 

Waseem Sajjad; Medical Officer: Literature 

search, Data analysis, Manuscript preparation. 

Wamiq Mehmood; Postgraduate Registrar: Data 

acquisition, Manuscript editing, Manuscript 

review. 

Aiman; Final Year Student: Literature search, 

Manuscript review, Final approval. 

 
.…


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