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Home , Allergic conjunctivitis

FROM OUR SOUTH ASIA EDITION Allergic conjunctivits VPEI Rathi/ L V (c)

Roughness of epithelium as seen in shield ulcer

Varsha M Rathi allergic . The most cotton with allergic and allergic Faculty, Tej Kohli Institute, important symptom of allergic conjunctivitis.8 Seasonal peak is seen Gullapalli Pratibha Rao International conjunctivitis is itching. Table 1 lists during April to August in patients having Center for Advancement of Rural 9 Care, L V Prasad Eye Institute, spectrum of disorders of allergic VKC. 3 Hyderabad, India conjunctivitis. Classification Somasheila I Murthy Faculty, Tej Kohli Cornea Institute, Epidemiology Seasonal allergic conjunctivitis: L.V. Prasad Eye Institute, Kallam Anji The diagnosis of allergic conjunctivitis is This condition is common, is seen Reddy Campus, Hyderabad, India on the increase. SAC and PAC accounts among all ages and occurs seasonally for 15-20% of cases of allergic when is released in May and The diagnosis of allergic diseases has conjunctivitis.4 The disease is more June. Itching followed by watering and a increased in the last few decades and common in hot, humid tropical burning sensation is seen in these allergic conjunctivitis has emerged as a climates.5 VKC has been reported from patients. Sometimes, it may be significant problem, which can cause many Asian countries e.g. Nepal, associated with a running nose (allergic severe ocular surface disease. Patients Pakistan and India.2,6,7 VKC and AKC rhinitis or rhinoconjunctivitis). Patients complain of itching, watering and may cause corneal and ocular surface may complain of sinus pressure behind redness. It can result in decreased involvement leading to severe visual the eye. quality of life, as patients with severe loss. Numerous factors such as symptoms, if left untreated or treated changing climates, increasing pollution, Perennial allergic conjunctivitis: poorly, may become school dropouts, genetics, cigarette pollutants and PAC has similar signs and symptoms to unable to work outdoors and sometimes occurrence of in early childhood SAC and as the name suggests it occurs fail to sleep. The symptoms are have been proposed as causative throughout the year. PAC is due to aggravated by exposure to dry and windy agents or risk factors. Significant allergy to animal dander, mites and 1,2 climates. This article aims to provide a correlations have been observed with feathers. The frequency of occurrence brief overview of the management of mixed pollen, thresher dust and raw increases as the age increases.10 The

Table 1. Disorders of allergic conjunctivitis

Mild allergic Severe allergic Chronic microtrauma conjunctivitis conjunctivitis related disorders Seasonal Vernal Contact induced conjunctivitis (SAC) (VKC) papillaryconjunctivitis (CLPC) Perennial Atopic Giant papillary conjunctivitis (PAC) keratoconjunctivitis (AKC) conjunctivitis (GPC)

© The author/s and Community Eye Health Journal 2015. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 99 | 2017 S 7 article distributed under the Creative Commons Attribution Non-Commercial License. FROM OUR SOUTH ASIA EDITION

patients have itching, redness and individuals. In Asia, the mixed form is Corneal involvement in VKC may occur swelling of . Corneal more common compared to the limbal as corneal epithelial punctuate , involvement in SAC and PAC is rare.4 form, which is seen in Africans.7 and where the epithelial erosions may However, studies from India and Nepal coalesce and form a vernal or a shield Vernal keratoconjunctivitis: have reported that the bulbar form of ulcer. Presence of shield ulcer will VKC is a disease of warm climates and the disease is common in some worsen patients’ symptoms and affect occurs predominantly in young males areas.2,9 vision. These ulcers are oval and are (8-12 years of age).2,11 Although VKC is Limbal or bulbar form may present as usually present in the upper part of the more common in children, adults may gelatinous thickening of the limbus, cornea. The shield ulcers are classified also have VKC.12,13 presence of papillae at the limbus and based on the presence of white material It is a bilateral disease and may yellow Horner-Tranta’s dots (Figure 1) at the base of the ulcer. Based on the worsen with exposure to wind, dust and usually at the superior limbus. These grades of shield ulcer, the treatment sunlight. These patients may have dots are seen when the disease is active options differ.15 positive history of or eczema. and indicate severity of the disease. Patients present with severe itching The hallmark of the palpebral VKC is Atopic keratoconjunctivitis: (rubbing of usually with a knuckle), presence of giant papillae, which are AKC is a bilateral disease of ocular redness, discharge, and . seen on everting the upper lid – the surface and lids, which occurs The mucus discharge is thread-like. giant papillae have a cobble stone throughout life. The patients will have School-going children may drop out appearance (Figure 1). This thickening eczematous skin lesions of the body. from going to school because of severe of the upper lid may be associated with The conjunctiva may have papillae or itching and photophobia. drooping of the lid (). Conjunctival Trantas dots. formation can Three clinical forms of VKC are pigmentation is common in patients occur in these patients. Table 2 shows described: limbal or bulbar, palpebral having VKC. 14 the differentiating features of VKC and and mixed (Figure 1). Limbal form is The mixed form of VKC has features AKC. more common in dark skinned of both palpebral and limbal VKC.

Figure 1. Clinical forms of VKC: Limbal or bulbar, palpebral and mixed

Limbal form of VKC: Gelatinous Palpebral form of VKC: Cobble stone translucent appearance papillae seen after flipping of upper lid

Yellow Horner Trantas dots: more the dots, Roughness of epithelium as severe is the disease seen in shield ulcer

S 8 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 99 | 2017 FROM OUR SOUTH ASIA EDITION

Table 2. Differentiating features of vernal and atopic keratoconjunctivitis

VKC AKC

Age Young Old Sex Males > Females Equal ratio Season Spring Perennial Duration Limited Chronic Skin involvement No Yes, extra lid fold, maceration of canthi Punctal stenosis No Yes Conjunctiva Upper tarsal Lower tarsal conjunctiva conjunctiva Conjunctival scarring Rare Common Cornea Shield ulcer Epithelial defects Scarring Peripheral Central Vascularization Rare Common VKC: vernal keratoconjunctivitis AKC: Allergic keratoconjunctivitis

Giant papillary conjunctivitis: been reported in these patients.7 The mainstay of treatment is the use of The presence of a , ocular Complications may lead to irreversible lubricants, anti- and mast prosthesis or sutures may sensitize and visual loss in some patients.7 Both the cell stabilizers.16,20 These are indicated cause trauma to the upper tarsal complications, and LSCD in all forms of disease. Steroids are to conjunctiva with the formation of giant need timely surgical treatment to be given under proper medical care papillae. Removal of these external prevent visual malfunction. when the cornea is involved or the agents will reduce the papillae. disease is very severe with itching. Toxic allergic reactions may also be Diagnosis Overuse of may cause due to drugs such as neomycin, Appropriate management of allergic steroid induced and atropine, epinephrine or preservatives in conjunctivitis needs a correct diagnosis. and may result in blindness. The drugs medicines such as thiomersol.16 Figure 2 gives a guide for such diagnosis that are used are: and ways to differentiate from other stabilizers: disodium Contact reactions: causes of red eyes. Presence of itching cromoglyacate (not effective in acute The pattern of involvement depends is a hallmark of ocular allergy. stages), and Lodoxamide upon severity of the reaction and the : , dual acting site of contacts. Patients may have lid Management drugs such as olapatadine, , swelling, redness, chemosis, follicular Though some authors have described and bepostatine. Immediate reaction and later sometimes management protocols, there are no symptomatic relief is possible with cicatrisation. The corneal involvement universally accepted protocols of azelastine and epinastine, which are may be in the form of superficial management for allergic eye currently preferred. punctate keratitis, pseudodendrites or diseases.11,12 Various drugs are available Corticosteroids: such as prednisolone grayish stromal infiltrates.17 and the treatment options vary based are given for a short duration during on the severity of the disease. It is acute allergic disease; oral steroids or Complications important to avoid any known supratarsal injection of corticosteroids Most often, the complications are or reduce exposure to it by using wrap- is required if the disease is severe. because of poor compliance to around glasses, by changing the Nonsteroidal anti-inflammatory treatment on the part of patient, or environment, replacing allergen- agents (NSAIDS): ketorolac, inadequate control of the disease when harbouring items such as pillows and diclofenac can be added to it presents in its severe form. Common carpets. However, such antihistamines. Steroid sparing agents complications include dry eye, infection recommendations may be challenging such as Cyclosporine A, Tacrolimus are and corneal scar. Chronicity of the for patients. In addition, cool effective in severe AKC and VKC. untreated disease may lead to vision compresses can be done to prevent threatening problems like limbal stem rubbing of the eye. Ocular lubricating Conclusion cell deficiency (LSCD) and secondary eye drops can be used to dilute the From a public health perspective, the keratoconus due to rubbing of the eyes. inflammatory agents in and wash number of patients being diagnosed As the treatment involves use of away the allergen to reduce itching and with allergic conjunctivitis is increasing. corticosteroids, steroid-induced raised to prevent further worsening of However, not many studies are and cataract have symptoms. 19

© The author/s and Community Eye Health Journal 2015. This is an Open Access COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 99 | 2017 S 9 article distributed under the Creative Commons Attribution Non-Commercial License. FROM OUR SOUTH ASIA EDITION

available from South East Asia, which necessitating the need for medications especially about good general hygiene; give a complete picture of allergic eye to continue for years.21,22 avoidance of ; cold disease. Severe conjunctivitis such as Management of the disease is very compression; change of environment; VKC, being a disease of the young may challenging and a multipronged increase the number of school dropouts approach with well–trained primary and and judicious use of corticosteroids in these countries. Economic costs for secondary care personnel to educate may improve ocular health in patients patients are high, sometimes patients or parents about the disease, by leaps and bounds.

Figure 2. A guide to aid diagnosis of allergic conjunctivitis

References

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