title: Tailored approach to the treatment of vernal keratoconjunctivitis.
abstract: OBJECTIVE
  To develop a standardized clinical grading system for the management of patients with vernal keratoconjunctivitis (VKC) and to identify the risk factors associated with a worsened outcome of the disease, including decrease of visual acuity and ocular complications development.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  A total of 207 consecutive patients with VKC, referred to our Cornea and External Diseases Center from 1997 to 2007, were included in the study. A total of 110 of those patients were included in the follow-up study (range 1-10 years).
  
  
  METHODS
  Classification and regression tree (CART) analysis was performed to separate the patients into 5 subgroups by therapeutic approach. Regression tree and multivariate logistic regression analyses were performed during follow-up to identify predictors of worse visual outcome.
  
  
  METHODS
  Age, gender, duration and course of disease, signs, symptoms, overall symptoms score, history of atopy, markers of allergy, best-corrected visual acuity, and therapy were collected at baseline and during follow-up. The number of relapses and number of patients with decreased visual acuity were also evaluated in the follow-up.
  
  
  RESULTS
  A decision tree for VKC treatment was developed by CART analysis, and a new clinical grading system was proposed accordingly. Sixteen patients were classified as grade 0 (absence of symptoms and no therapy); 59 patients were classified as grade 1 (presence of symptoms without photophobia, occasional use of anti-allergic eye drop); 74 patients were classified as grade 2 (presence of symptoms including photophobia, daily anti-allergic treatment); 22 patients with superficial punctuate keratopathy (SPK) were classified as grade 3 (daily anti-allergic treatment associated with occasional topical steroid); and 36 patients were classified as grade 4 (diffuse SPK or corneal ulcer; pulsed high-dose topical steroid). A higher number of relapses and a higher baseline grade of VKC were the main predictor factors for worse visual outcome.
  
  
  CONCLUSIONS
  This grading system allows for identifying the more severe forms of VKC that are at higher risk of recurrences, corneal ulceration, and worse final visual outcome.
  
  
  BACKGROUND
  The author(s) have no proprietary or commercial interest in any materials discussed in this article.
authors.affiliation: Department of Ophthalmology, University of Rome, Campus Bio-Medico, Rome, Italy.
authors.forename: Marta
authors.initials: M
authors.lastname: Sacchetti
authors.forename: Alessandro
authors.initials: A
authors.lastname: Lambiase
authors.forename: Flavio
authors.initials: F
authors.lastname: Mantelli
authors.forename: Velika
authors.initials: V
authors.lastname: Deligianni
authors.forename: Andrea
authors.initials: A
authors.lastname: Leonardi
authors.forename: Stefano
authors.initials: S
authors.lastname: Bonini
mesh_terms: D000293:Adolescent; D000328:Adult; D018926:Anti-Allergic Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D003233:Conjunctivitis, Allergic / Q000145:classification* / Q000188:drug therapy* / Q000503:physiopathology; D003663:Decision Trees; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D014792:Visual Acuity / Q000502:physiology
chemical_list: D018926:Anti-Allergic Agents; D005938:Glucocorticoids