In a school‑age boy with vernal keratoconjunctivitis who frequently rubs his eyes, does the disease cause retinal nerve‑fiber layer thinning, and how should we monitor and manage the risk of glaucoma?

RNFL Thinning and Glaucoma Risk in VKC with Eye Rubbing

Yes, vernal keratoconjunctivitis with frequent eye rubbing does cause retinal nerve fiber layer damage and glaucomatous optic neuropathy, requiring aggressive monitoring and intervention to prevent permanent vision loss.

Mechanism of RNFL Damage

Chronic eye rubbing in VKC patients causes posterior segment complications through multiple pathways 1:

• Direct mechanical trauma: Vigorous rubbing creates distending forces that spike intraocular pressure acutely, damaging the optic nerve over time 1
• Inflammatory cascade: Inflammatory molecules released during rubbing serve as mediators between the mechanical trauma and glaucomatous optic neuropathy 1
• Steroid-induced glaucoma: The necessary use of topical corticosteroids for VKC flare-ups independently elevates IOP, compounding the rubbing-related damage 2, 3

The combination is particularly devastating—approximately 6% of VKC patients develop glaucoma as a long-term complication 3, and this risk escalates dramatically with chronic eye rubbing and steroid exposure 4.

Monitoring Protocol

Implement quarterly comprehensive glaucoma screening that includes:

• IOP measurement at every visit to detect both rubbing-induced spikes and steroid-response elevation 1, 2
• Optic nerve head examination with dilated fundoscopy looking specifically for cupping and pallor 1
• RNFL thickness assessment using optical coherence tomography (OCT) every 3-6 months to detect early thinning before visual field loss occurs 1
• Visual field testing annually or sooner if structural changes are detected 3

Management Strategy

Immediate Interventions

Eliminate eye rubbing as the primary therapeutic goal 1:

• Educate the patient and parents that rubbing directly causes blindness through glaucoma and keratoconus 1
• Prescribe aggressive anti-allergy therapy to reduce itching triggers 5
• Consider protective eyewear or mittens at night for young children who rub unconsciously 1

Pharmacologic Management

Use steroid-sparing agents as first-line therapy 5:

• Topical cyclosporine A 2% is effective for long-term VKC control without IOP elevation 5, 3
• Tacrolimus as an alternative immunomodulator 5
• Dual-acting agents (olopatadine) and mast cell stabilizers (lodoxamide) for baseline control 2

Reserve topical corticosteroids strictly for severe flare-ups 2, 3:

• Use only for brief periods (days, not weeks) 3
• Monitor IOP within 1-2 weeks of initiating steroids 2
• Switch to immunomodulators as soon as inflammation is controlled 5

Critical Pitfall

The most dangerous scenario occurs when patients use unsupervised topical steroids during flare-ups, as documented in a recent case where this led to steroid-induced glaucoma complicating both VKC and keratoconus management 4. Never allow patients to have unrestricted access to topical steroids 4.

Risk Stratification

This school-age boy is in the highest-risk category because:

• Male gender and young age are typical for severe VKC 2, 3
• Active eye rubbing behavior is present 1
• The disease duration will likely span years, maximizing cumulative damage 2

Refer immediately to a pediatric ophthalmologist or glaucoma specialist if any of the following develop 3:

• IOP >21 mmHg on repeated measurements
• Optic nerve cupping or RNFL thinning on imaging
• Corneal changes suggesting keratoconus (another rubbing complication) 1
• Need for prolonged steroid therapy 2