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Home , Allergic conjunctivitis, Blepharitis

Ophthalmic Pearls

EXTERNAL DISEASE

The Itchy : Diagnosis and Management of Ocular Pruritus

by jocelyn kuryan, md, prabjot channa, md, and roy s. chuck, md, phd edited by ingrid u. scott, md, mph, and sharon fekrat, md

cular pruritus is a com­ , giant papillary conjunc­ mon symptom that brings tivitis and contact dermatoblepharitis. patients to the ophthalmol­ A complete history, review of systems ogist’s office. It may be and examination can help differentiate tempting to overlook this among these etiologies. Oseemingly minor problem while as­ sessing patients for potentially vision- Pathophysiology threatening diseases. However, itchy Many of the causes of ocular pruritus can be a major problem and are immunologically mediated. source of anxiety for patients, often af­ • and AKC fecting their day-to-day quality of life. are a result of IgE-mediated reactions Although a physician’s inclination that cause mast-cell degranulation CONTACT COMPLICATION. Giant may be simply to treat the symptom and release. IgE-mediated papillary conjunctivitis. with topical mast-cell stabilizers or an­ processes as well as impaired cellular tihistamines, it is important to identify immunity and genetic factors also con­ the action of local inflammatory me­ the underlying cause. By carefully and tribute to atopic . Both type diators in the setting of hyposecretion methodically determining the etiology I (immediate) and type IV (delayed) and obstruction of the meibomian of ocular pruritus, the clinician can se­ reactions are involved gland orifices. lect an appropriate treatment regimen in vernal . Con­ • DES can be caused by either aque­ and provide patients with the relief junctival scrapings from patients with ous tear deficiency (either Sjögren or they seek. allergic conjunctivitis, AKC and vernal non-Sjögren type) or evaporative tear keratoconjunctivitis will reveal eosino­ dysfunction (which includes MGD). What Causes Itchy Eyes? phils that are not part of the normal Patients suffering from Sjögren syn­ Pruritus can be the chief complaint for conjunctival histology. drome also have autoimmune dysregu­ a number of ocular surface diseases. • Contact dermatoblepharitis is the lation. Atopic keratoconjunctivitis, vernal result of a type IV –mediated keratoconjunctivitis, allergic conjunc­ hypersensitivity reaction, which is why History tivitis and are part of symptoms can take one to three days A thorough history and review of the spectrum of ocular . Other to manifest. systems should include special atten­ causes of pruritus include dry eye • is also believed to have tion to onset, duration and frequency syndrome, dysfunc­ an immunologic basis, as symptoms of symptoms, as well as exacerbating tion, blepharitis, –induced may result from a reaction to staphylo­ factors and associated systemic com­ coccal antigens. plaints. The following questions may Acronyms • The etiology of conjunctivitis in­ help narrow the differential: duced by contact lenses is multifacto­ • Do your eyes throughout the AKC Atopic keratoconjunctivitis rial, including mechanical trauma, dry year? Perennial complaints are often DES eye syndrome and hypersensitivity to associated with allergic conjunctivitis GPC Giant papillary conjunctivitis contact lenses and/or solution as well and AKC. MGD Meibomian gland dysfunction as to protein deposits on the lenses. • Do your eyes burn and/or tear? Do

BCSC, Section 8, courtesy of Kirk R. Wilhelmus, MD • The pathogenesis of MGD involves you have foreign body sensation? All

eyenet 35 Ophthalmic Pearls may be symptoms of dry eyes and/or severity and location tend to vary. Atopic dermatitis. Eliminate envi­ MGD. • Patients with vernal keratocon­ ronmental and food . Exac­ • Do you have , allergic junctivitis may have giant papillae or erbations on the skin can be treated and/or eczema/skin rashes? A diffuse papillary hypertrophy of the with cream or immuno­ positive response may suggest allergic upper palpebral . Small modulators (e.g., tacrolimus) in severe conjunctivitis, AKC and atopic derma­ papillae tend to be located on both the cases. Moisturizing the facial skin titis more strongly; these conditions upper and lower palpebral conjunc­ (specifically the ) is important are frequently linked. tiva in AKC, while papillae are more for long-term treatment. Systemic an­ • Do you wear contact lenses? Con­ prominent on the upper palpebral tihistamines and mast-cell stabilizers tact lens overwear, poorly fitting lenses conjunctiva in contact lens–induced may also provide relief. and/or improper hygiene can lead to conjunctivitis. Dry eye syndrome. Lubrication of contact lens–induced conjunctivitis Conjunctiva. Conjunctival signs the ocular surface is the ultimate goal. or GPC. Soft contact lenses tend to include: Initial treatment with artificial (if induce more pruritus than rigid gas • Mild to moderate bulbar conjuncti­ the tears are used more often than four permeable lenses. val hyperemia and/or chemosis, which times daily, then a preservative-free • Can you identify any triggers? Ex­ is seen in most cases of ocular pruritis. formulation is necessary) and with lu­ posure to pet dander or environmental • Varying degrees of mucoid discharge bricant at bedtime, is acceptable. Some allergens can often trigger allergic may also be seen. patients may also require punctal conjunctivitis. Patients with vernal . Check the cornea for: plugs. Those who remain symptomatic keratoconjunctivitis tend to be more • Punctate epithelial erosions, which may need topical cyclosporine A to in­ symptomatic in warmer climates. are a common finding in the patient crease tear production. • Have you used any new products, with itchy eyes. Pannus and corneal Allergic conjunctivitis. Once again, such as creams, makeup, soap or eye- vascularization may be present and it is important to avoid or eliminate al­ drops? Itchiness caused by exposure to vary according to disease severity. lergic triggers whenever possible. Sup­ a sensitizing agent is often seen with • Marginal epithelial infiltrates can portive care with cool compresses can contact dermatoblepharitis or blepha­ be present in MGD and contact lens– be helpful for some patients. The use roconjunctivitis. Symptoms tend to induced conjunctivitis. of physical barriers (such as glasses) develop within one to three days of • Horner-Trantas dots (raised, ge­ is also useful in limiting con­ exposure. latinous collections at the limbus) and tact. Artificial tears will help dilute shield ulcers are classically associated any allergen remaining on the ocular Examination with vernal keratoconjunctivitis. surface. Topical vasoconstrictors (e.g., A thorough examination will help re­ , naphazoline, oxymeta­ veal the underlying pathology. Management and Treatment zoline) can be used on a short-term ba­ . Pay particular attention to Once the diagnosis has been made, an sis for symptomatic relief. For patients the eyelids for: appropriate treatment course can be with more severe symptoms, topical • Eyelid margin and , selected (“Common Causes and Treat­ (e.g., , ), oral and which can be seen with most of the ments for Ocular Pruritis,” next page). intranasal and mast- conditions described. Contact dermatoblepharitis/ cell stabilizers (e.g., cromolyn sodium, • Scaling of the eyelids, blepharoconjunctivitis. First, it is im­ lodoxamide) are often beneficial. Topi­ and leathery thickness of the eyelid perative to identify and discontinue cal NSAIDs and should (lichenification) are associated with use of the offending agent. Contact be used with caution and require atopic dermatitis and chronic contact reactions to topical carbonic anhy­ frequent follow-up. Consultation with dermatoblepharitis. drase inhibitors and brimonidine are an allergist for desensitization therapy • Periorbital hyperpigmentation (“al­ commonly delayed several weeks or may be necessary for those patients lergic shiners”) may point to an aller­ months. Once the irritant is elimi­ who remain symptomatic despite these gic cause. nated, supportive treatment, including measures. • Blepharitis can result in crusting of the use of cool compresses, is usually Vernal keratoconjunctivitis/atopic the eyelid margin and collarettes at the sufficient. Ocular lubrication with keratoconjunctivitis. Symptoms may base of the . artificial tears or ointment is also help­ be alleviated with topical antihista­ • MGD can cause inspissation of the ful. Additional therapies include the mines and mast-cell stabilizers. How­ meibomian gland orifices, foamy tears, use of mast-cell stabilizers, topical an­ ever, these patients tend to require eyelid margin , pucker­ tihistamines and topical nonsteroidal more aggressive measures compared ing and recurrent chalazia. anti-inflammatory drugs (e.g., ketoro­ with those suffering from allergic • Papillary reactions of the palpebral lac). Topical corticosteroids applied to conjunctivitis. Topical corticosteroids conjunctiva are seen with many of the the eyelid can hasten recovery in more and even immunomodulators (such aforementioned conditions, but the severe cases. as cyclosporine A) may be necessary.

36 february 2010 Ophthalmic Pearls

Supratarsal corticosteroid injections have also been used to control symp­ Common Causes and Treatments of Ocular Pruritus toms. Patients with AKC are more Contact dermatoblepharitis/ Remove offending agent prone to infectious complications blepharoconjunctivitis Cool compresses, artificial tears (especially ) Mast-cell stabilizers and topical antihistamines and should, therefore, be monitored Topical NSAIDs (e.g., ketorolac) and corticosteroids closely. Vernal keratoconjunctivitis as needed classically affects young men in warm climates; these patients may find relief Atopic dermatitis Remove offending agent in cooler climates or air-conditioned Topical corticosteroid cream or immunomodulators environments. Shield ulcers may re­ for skin symptoms (e.g., tacrolimus) quire plaque debridement and scraping Lubrication of eyelids at the ulcer base followed by aggressive Systemic antihistamines and mast-cell stabilizers treatment with topical corticosteroids Dry eye syndrome Artificial tears and lubricating ointments and . Punctal plugs Contact lens­–­­induced conjuncti- Topical immunomodulators (e.g., cyclosporine A) vitis/giant papillary conjunctivitis. Allergic conjunctivitis Remove offending agent Patients should first be advised to (seasonal and perennial) Cool compresses discontinue contact lens wear until Eyeglasses to shield from allergens the exacerbation has resolved. It is Artificial tears also appropriate to refit the lenses or Topical vasoconstrictors (e.g., pheniramine, naph- to try different lenses and to advise azoline, oxymetazoline) for short-term symptomatic patients about proper hygiene. It may relief be helpful to change to daily-wear Topical (e.g., olopatadine, ketotifen) as well as oral contact lenses. Once the exacerbation or intranasal antihistamines, and mast-cell stabiliz- has ­resolved, mast-cell stabilizers are ers (e.g., cromolyn sodium, lodoxamide) sometimes used as maintenance ther­ Topical NSAIDS and corticosteroids apy. For those who remain intolerant, Consultation with an allergist for desensitization refractive is an alternative. therapy Meibomian gland dysfunction/ Vernal keratoconjunctivitis Topical antihistamines and mast-cell stabilizers blepharitis. Education regarding Topical corticosteroids and immunomodulators proper eyelid hygiene is imperative. (e.g., cyclosporine A) Warm compresses and twice-daily Supratarsal corticosteroid injection eyelid scrubs can help open inspissated meibomian glands. A clean washcloth Atopic keratoconjunctivitis Similar treatment as for vernal keratoconjunctivitis dipped into baby shampoo diluted Contact lens–induced Discontinue contact lens use with water is commonly used for eyelid conjunctivitis/giant papillary Refit contact lenses massage and scrubbing. Ocular surface conjunctivitis Proper contact lens hygiene lubrication with artificial tears can Mast-cell stabilizers for maintenance provide additional relief. Short-term May consider refractive surgery in refractory cases use of a topical (macrolides Meibomian gland dysfunction/ Eyelid hygiene are often used) may be beneficial, blepharitis Artificial tears while some patients will require a Topical antibiotics (e.g., macrolides) course of oral tetracyclines that are Course of oral tetracyclines followed by taper then tapered off. Staphylococcal mar­ Short course of topical corticosteroids ginal keratitis will often require the use of topical corticosteroids to quell a short-term basis due to the risk of Management of patients with systemic the inflammatory response. corneal melts and perforation. Patients complaints is often facilitated by con­ taking topical corticosteroids also sultation with an allergist. Follow-Up require close monitoring for super­ Frequent follow-up is often necessary infection and for the development of Dr. Kuryan is chief resident, Dr. Channa is for patients with ocular pruritus. Pa­ corticosteroid-induced ocular hyper­ assistant professor of cornea and external dis­ tients on topical NSAIDs need close tension. For those patients who require eases and Dr. Chuck is chairman of ophthal­ monitoring (to date, only ketorolac is an extended course of topical cortico­ mology and visual sciences. All are at Monte­ FDA-approved for this condition), and steroids, combination therapy with a fiore Medical Center and the Albert Einstein NSAIDs should only be prescribed on topical antibiotic may be indicated. College of Medicine, Yeshiva University.

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