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M. Sacchetti, A. Lambiase, V. Deligianni, F. Mantelli, A. Leonardi, S. Bonini; A New Clinical Grading of Vernal Keratoconjunctivitis: A Classification-Regression Tree (cart®) Analysis. Invest. Ophthalmol. Vis. Sci. 2010;51(13):1932.
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Vernal keratoconjunctivitis (VKC) is a chronic allergic disease with seasonal recurrences and possible corneal involvement. We aimed at developing a standardized clinical grading system for the management of VKC patients and identifying risk factors for worse visual outcome.
Clinical signs (conjunctival hyperemia, chemosis and secretion, upper tarsal and limbal papillary reaction, corneal epitheliopathy and ulcer) and symptoms (itching, tearing, burning and photophobia) were evaluated as follows in 207 patients with VKC (45F, 162M, mean age 10±6 years): 0=absent, 1=mild, 2=moderate, 3=severe. A decision tree was developed with classification tree analysis (CART®), which separated patients in 5 subgroups based on the therapeutic approach and identified 5 grades of severity. 110 of these patients were included in a 10-years follow-up study. Demographic data, clinical history, best corrected visual acuity (BCVA), VKC grade and therapy were collected at baseline and during follow-up. CART® analysis and multivariate logistic regression analysis were performed to identify predictors of worse visual outcome.
CART® analysis identified 5 grades of VKC severity: 0-quiescent (n=16): absence of symptoms, no therapy; 1-mild (n=59): presence of symptoms without photophobia, occasional use of anti-allergic eye drop; 2-moderate (n=74): presence of symptoms including photophobia, daily anti-allergic treatment; 3-severe (n=22): presence of superficial punctuate keratopathy, daily anti-allergic treatment and occasional pulsed low dose topical steroid; 4-very severe (n=36): diffuse corneal epitheliopathy and/or ulcer, pulsed high dose topical steroid. During follow-up 7% of patients showed a decrease of more than two lines in BCVA (mean final BCVA 0.9 ± 0.1). A higher recurrence rate and a higher baseline grade of VKC were the main predictors for worse visual outcome.
This grading system allows identifying the more severe forms of VKC that are at higher risk of recurrences, corneal ulcer, and worse final visual outcome.
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