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Ocular Allergies

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Ocular Allergies 7/29/2009 Learning Objectives Understand the pathophysiology of ocular allergies Ocular Allergies Identify the aetiologies and clinical features of allergic conjunctivitis Recognise the various forms of allergic eye disease Dr Dipika Patel Discuss the various drugs used in the treatment of Clinical Senior lecturer ocular allergies Department of Ophthalmology Formulate an appropriate management plan SAC - Seasonal Allergic Conjunctivitis Types of Ocular Allergic Disease Most common ocular allergy Half of ocular allergies 10 to 30% world population Seasonal Allergic Conjunctivitis (SAC) Incidence doubled last 10 years (atmospheric Perennial Allergic Conjunctivitis (PAC) pollution) Rarely appears before 5 years of age Contact Lens Papillary Conjunctivitis (CLPC) Allergic response mediated by mast cells Vernal Kerato-Conjunctivitis (VKC) Ocular component of hayfever (tree, grass, weed pollen) Atopic Conjunctivitis Occurs when pollen counts high Experience symptoms when count reaches “moderate” (30-49 pollen grains/cubic metre air) 1 7/29/2009 SAC - Seasonal Allergic Conjunctivitis SAC - Seasonal Allergic Conjunctivitis Signs Symptoms Bulbar conjunctival hyperaemia Red, itchy, burning & watery & oedema eyes Eyelid chemosis and oedema Dryness/irritation Mild watery discharge Papillary hypertrophy of upper Discomfort palpebral conjunctiva (redness & Mucoid discharge roughness) Cornea rarely involved PAC - Perennial Allergic PAC - Perennial Allergic Conjunctivitis Conjunctivitis 1% of allergy sufferers 90% of housing are contaminated by specific moulds Year round disease due to dust, animal Allergies to moulds are known since 1873 skin and hair, mould, fungus etc Prevalence of allergies to moulds is 20 to 30% for atopic people Allergic response mediated by mast cells 3 to 10% of adults and children (worldwide) Signs and symptoms very similar to SAC would suffer of allergies to moulds Chronic and less severe Even if it is a perennial problem there are some seasonal peaks due to heat and humidity Continue throughout year with seasonal exacerbation 2 7/29/2009 PAC - Perennial Allergic CLPC – Contact Lens Conjunctivitis Associated Papillary Conjunctivitis Symptoms Very similar to SAC Incidence 2% – 15% depending on lens type burning Immune and/or mechanical response primarily itching affecting superior tarsal conjunctiva watering eyes Response mediated by T-cells sometimes mucoid secretions CLPC – Contact Lens CLPC – Contact Lens Associated Associated Papillary Papillary Conjunctivitis Conjunctivitis CAUSES Aetiology Mechanical Lens edge, material stiffness or poor surface Mechanical quality of CL in contact with conjunctiva Solution related Mineral deposits from tears Allergy Immune reactions Denatured proteins, accumulated on CL surface 3 7/29/2009 CLPC – Contact Lens CLPC – Contact Lens Associated Papillary Associated Papillary Conjunctivitis Conjunctivitis Signs CAUSES Palpebral hyperaemia Cytotoxic components of CL solutions Preservatives Tarsal roughness and enlarged papillae Antiseptic Conjunctival oedema Wetability agents Mucous strands Enzymes Mild ptosis if severe CLPC Symptoms VKC - Vernal Keratoconjunctivitis Mucous discharge Rare but severe: affects children and more often boys Itchiness, irritation (gender ratio 2/1) Blurred vision Resolves at adult age Lens deposition No specific allergen is clearly at the origin of VKC Children who have VKC have a higher incidence of Lens dislocation keratoconus than the general population Discharge Reduced CL comfort and wearing time Asymptomatic in early stages 4 7/29/2009 VKC - Vernal Kerato- Atopic Keratoconjunctivitis Conjunctivitis Symptoms Intense photophobia Mucus discharge Resembles VKC but not Clinical aspects seasonal Hyperaemia Conjunctival oedema Adults Giant papillary (>1mm) on superior Associated with atopic tarsal conjunctiva Corneal staining dermatitis In advance cases: shield ulcer Superinfection with staphylococcus Diagnosis of Allergic Conjunctivitis Diagnosis of Allergic Conjunctivitis •Clinical history Clinical examination and investigations •Typical symptoms Appearance of the everted (flipped) eyelid. •80% of patients are under 30 years of age Skin prick/puncture tests or specific IgE tests to •Strong personal or family history of IgE-mediated diseases identify causative allergens • •Recurrent, intermittent or persistent symptoms 5 7/29/2009 Diagnosis of Allergic Differential diagnosis Allergic Conjunctivitis Conjunctivitis •Blepharitis Mediators of IgE-related reactions in allergic conjunctivitis •Bacterial conjunctivitis Histamine: Itching, redness, oedema •Chlamydial conjunctivitis •Corneal abrasion or ulceration Prostaglandins: Sensitized nerves, enhanced pain, oedema and redness •Dry eye •Episcleritis Leukotrienes: Chemotaxis, oedema and vascular permeability •Staphylococcal marginal keratitis Chemotactic factors: Recruitment of eosinophils and neutrophils •Superficial punctate keratitis leading to tissue destruction •Tight lens syndrome •Viral conjunctivitis or keratitis Treatment of ocular allergy Over-the-counter medications Allergen avoidance Topical decongestants Palliative Cold compresses Reduce chemosis and conjunctival hyperemia by Lubricants an alpha-adrenergic mechanism resulting in vasoconstriction -work within minutes (duration of Over-the-counter medications Topical decongestants/antihistamine about 2 hours). Oral antihistamine Prescription drugs o Phenylephrine Antihistamine o Naphazoline Mast cell stabilizing antihistamine NSAID’s Corticosteroids 6 7/29/2009 Over-the-counter medications But!! Decongestant/antihistamine combinations Antihistamines mildly suppress the immunological response. Side effects: rebound redness, dilation of the They help with itch more than straight decongestants. pupil, avoid in narrow angle glaucoma. oOpcon-A (0.315% pheniramine maleate, 0.02675% naphazoline hydrochloride) Decongestants mask the signs and symptoms of oVasocon-A (0.5% antazoline phosphate, 0.05% allergic conjunctivitis naphzaoline hydrochloride) oNaphcon-A (0.3% pheniramine maleate, 0.025% naphazoline hydrochloride) Chronic use of vasoconstrictors can lead to toxic, follicular reactions or possibly a contact dermatitis. Oral Antihistamines Over-the-counter medications •Oral antihistamines H1 antagonists Oral antihistamines should be used when patient has significant nasal problems (primary care physician) Do not prevent release of histamine Cetirizine (Zyrtec) Loratadine (Claritin) Inhibits contraction of bronchial smooth muscle These yield therapeutically effective concentrations of the drug at the anterior surface of the eye. Inhibits increased vascular permeability Several studies over the past few years have found topical allergy CNS effects include drowsiness drops to be more effective in relieving symptoms of allergic conjunctivitis than oral antihistamines*. *Concomitant use of a nasal spray plus a topical allergy drop (e.g., Flonase + Patanol) was more effective than a nasal spray (Flonase) + an oral antihistamine (Allergra) for overall treatment of signs and symptoms of allergic conjunctivitis. 7 7/29/2009 Over-the-counter medications Prescription drugs Topical antihistamines These drops work by competing with histamine for the H1 receptor Oral antihistamines sites. Have unexplained vasoconstrictive properties. All antihistamines (even nonsedating types) have a drying effect on the ocular surface. Antihistamines have atropine-like oLivostin (levocabastine 0.05%)--suspension; qid dosing for properties that decrease the tear production via the lacrimal 1-2 weeks, then 1-3 times/day as needed for itching. gland. They could also be decreasing mucin production by the goblet cells. oEmadine (emedastine dirfurmarate 0.05%)--virtually Be sure to check to see whether your patient is taking OTC identical to Livostin; same qid dosing; works immediately to antihistamines. reduce itch, redness, chemosis, and tearing. Side effects: Stinging, burning, headache, fatigue, nausea. Disadvantages: Do not prevent inflammation or release of histamine; short duration of action. Prescription drugs Mast cell stabilisers • Mast cell stabilizers Act by preventing release of Histamine A • Mast cell stabilizers work by inhibiting degranulation of mast cells (believed to prevent the influx of calcium to the mast cell). Sodium cromoglycate (Opticrom) • Mast cell stabilizers can be used for months Nedocromil sodium (Rapitil) without any significant side effects. Lodoxamide (Alomide) • They are good “prophylaxis” . (2,500 x more potent than sodium chromoglycate) • They can prevent the ocular allergic outbreak all together. 8 7/29/2009 Mast-cell stabilisers: Na cromoglycate Sodium cromoglycate (Opticrom) Course of treatment - QID Sodium cromoglycate Prophylactic Prophylaxis of ocular allergy and vernal Not an antihistamine conjunctivitis Ineffective once histamine released Stabilises membrane of mast cell Available over the counter as Opticrom Prevents release of Histamine Nedocromil sodium (Rapitil) Lodoxamide (Alomide) Superior/equal to sodium cromoglycate in: Mast cell stabiliser Vernal conjunctivitis Eosinophil inhibitor Seasonal allergic conjunctivitis Perennial conjunctivitis** 2,500 x more potent than sodium cromoglycate Effective against other inflammatory cells: macrophages, eosinophils & inhibits release TDS – QDS of inflammatory & chemotactic mediators All forms of allergic conjunctivitis Twice a day (**4 times per day) 9 7/29/2009 Prescription drugs Prescription drugs Mast cell stabilizing antihistamine NSAIDs
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