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DOI: 10.24125/sanamed.v14i3.349 UDK: 617.711-002 2019; 14(3): 235–239 ID: 281762316 ISSN-1452-662X Original article

THE EFFECT OF ALLERGIC CONJUCTIVITIS ON CHOROIDAL THICKNESS

Ayyildiz Taha,1 Yilmaz Mevlut,2 Ayyildiz Didem3 1 Kærsehir Ahi Evran University, Faculty of Medicine, Department, Kærsehir, Turkey 2 Turkey Kærsehir Ahi Evran University, Faculty of Medicine, Ophthalmology Department, Kærsehir, Turkey 3 Kærsehir Ahi Evran University, Training and Research Hospital, Child and Adolescent Psychiatry Department, Kærsehir, Turkey

Primljen/Received 02. 08. 2019. god. Prihva}en/Accepted 01. 11. 2019. god.

Abstract: Background: To examine the effects of Key words: Allergic , Antihistami- allergic conjunctivitis and its treatment upon choroidal ne, Choroidal thickness, Topical eyedrops, Treatment. thickness (ChT) using topical antihistaminic agents. Methods: 60 of 30 children and adolescents INTRODUCTION with allergic conjunctivitis and 60 eyes of 30 healthy controls participated in the study. Inclusion criteria for Allergic conjunctivitis is one of the most common patient groups were best-corrected visual acuity 20/20 ocular disorders in pediatric patients and defined as a or better, normal (IOP) and no sys- Type 1 reaction in which the igE me- temic or ocular diseases other than allergic conjuncti- diated response is involved. There are different types vitis. Healthy controls recruited from children and ado- of allergic conjunctivitis such as acute, subacute aller- lescents who had no ocular or chronic systemic disor- gic conjunctivitis, vernal and atopic keratoconjunctivi- ders and had best-corrected visual acuity 20/20 or bet- tis. Acute allergic conjunctivitis is a common acute co- ter and normal IOP. ChT was measuredby using En- njunctival reaction in children, which usually develops hanced Depth Imaging Optical Coherence Tomogra- in spring and summer due to environmental phy (EDI-OCT) before and after treatment by antihis- such as (1). tamine agents. The is a highly vascularized layer of the Results: Subfoveal choroidal thicknes mean va- formed of a dense capillary network and nourishes lue was 364.1 ± 63.8 mm in the allergic conjunctivitis the deep, outer two-thirds of the . In a limited group and the first-month values after the treatment number of studies evaluating choroidal thickness were 333.5 ± 52.1 mm. Subfoveal choroidal thickness (ChT) in children, there are contradictory results repor- means value in the control group was 320.6 ± 80.9 mm. ting that choroidal thickness increases (2) and decrea- There was a statistically significant decrease in ChT af- ses (3) in healthy children with age. In another study, ter treatment of allergic conjunctivitis patients and the- subfoveal choroidal thickness was thinner in patients re was a significant difference in terms of baseline ChT with like those in adults (4, 5). values between the allergic conjunctivitis group and Studies revealed that choroidal thickness was in- the control group. There was no significant difference creased in ocular pathologies particularly in central se- between one month after treatment values and the rous chorioretinopathy (CSCR). CSCR is an ophthal- mean values of the control group. mic disease which characterized by pigment epithelial Conclusions: Our results demonstrate that ChT detachment in the neurosensory retina due to increased can increase in allergic conjunctivitis patients and can vascular permeability and hydrostatic pressure and is become normal again with topical treat- associated with an increase in choroidal thickness ment. In order to support choroidal thickness to be a (6-9). In addition, increases in choroidal thickness in marker for the diagnosis and follow-up of allergic con- many inflammatory diseases with vascular involve- junctivitis, further studies with larger samples and lon- ment such as Juvenile Systemic Erythematosus gitudinal studies are needed. (10), Crohn’s Disease (11), Behçet’s Disease (12) and 236 Ayyildiz Taha,Yilmaz Mevlut, Ayyildiz Didem

Ankylosing Spondylitis (13) have been determined in ist in the outpatient clinic of Ophthalmology. Detailed previous studies. ophthalmologic examination including visual acuity, Embryologically, eye and brain development are intraocular pressure measurement was applied to all parallel to each other. The retina and the are cases. Patients with visual acuity £ 20/20 and any ocu- considered part of the central (CNS). lar or systemic disease diseases that might affect the Spectral Optical Coherence Tomography (SD-OCT) is choroidal thickness weren’t included in the study. All a non-invasive imaging technique that enables in vivo patients who have allergic conjunctivitis underwent visualization of the eye structures primarily used to SD-OCT examination before and after one-month anti- monitor retinal changes in (14). A method treatment. Then the initial values were com- called enhanced depth imaging spectral-domain opti- pared with one-month after treatment values. The ini- cal coherence tomography (EDI OCT) has been devel- tial and after one-month values were also compared oped to make possible in vivo cross-sectional imaging with the control group values. of the choroid (15). The research was carried out in accordance with Since allergic conjunctivitis is a common inflam- Helsinki declaration rules and informed consent forms matory condition in children, we aimed to investigate of patients were received. the probable relationship between increased choroidal thickness and allergic conjunctivitis. We first aimed to Oct Measurement examine whether ChT values showed differences bet- ween children and adolescents with allergic conjuncti- Choroidal thickness was evaluated with Spectral- vitisand healthy controls. Our second aim was to inves- Domain Optical Coherence Tomography (SD-OCT) tigate the effect of treatment by using topical antihista- (software version 6.3.3.0, Heidelberg Engineering mine agents on ChT. Inc., Heidelberg, Germany). This device produces high-resolution images from low infrared light levels. METHOD The device contained a superluminescent diode with a wavelength of 870 nm and could obtain 40.000 Sample A-scans per second. The axial and transverse resoluti- m The data obtained from the measurements of 60 ons were 7 and 14 m, respectively. All examinations eyes of 30 children and adolescents with allergic con- were performed between 9:00 a.m. and 12:00 noon, to junctivitis (study group) and 60 eyes of 30 healthy con- avoid the effect of diurnal variation on choroidal thick- trols (control group). Patients were admitted to the ness (16). These measurements were performed at the Ophthalmology outpatient clinic of Ahi Evran Univer- fovea on EDI-OCT mode which enables in vivo visual- sity Educational and Research Hospital in Febru- ization of the choroid (17). Choroidal thickness measu- ary-August 2017. Patients aged 9-17 years who have rements were performed in both eyes and the mean of firstly diagnosed with acute allergic conjunctivitis and the two measurements was evaluated. haven’t received any treatment were included. Healthy controls who admitted to the Child Psychiatry outpati- Statistical Analysis ent clinic in the same hospital with minor psychologi- All statistical analyses were performed using Sta- cal problems and had no ocular problems were recrui- tistical Package for Social Sciences-SPSS for IBM, ted. Allergic conjunctivitis diagnosis was based on de- 20.0. Kolmogorov-Smirnov test was used to assess the tailed history (episodic, seasonal, symptoms consist of normal distribution of continuous variables. ChT valu- itching, burning, watering) and ophthalmic examinati- es after one-monthof topical antihistamine treatment on by bio-microscope (papillary reaction in upper tar- were compared to the baseline using the paired test; af- sal or stringy discharge). Patients with al- ter seeing that all of the continuous variables were nor- lergic conjunctivitis were given difumarate mally distributed. The initial and one-month values one drop two times daily after diagnosis and they were were compared with the control groupby using student advised to stay away from an . Subfoveal cho- tests.The gender distribution of groups was evaluated roidal thickness measurements of the patients with al- by using the Chi-Square test. Statistical significance lergic conjunctivitis were performed at the first exami- was accepted as p < 0.05. nation and after 1-month than treatment. RESULTS Procedure Thirty children and adolescents with allergic con- Children and adolescents with allergic conjuncti- junctivitis (17 boys and 13 girls) and 30 healthy con- vitis and healthy controls were evaluated by a special- trols (16 boys and 14 girls) were included in the study. THE EFFECT OF ALLERGIC CONJUCTIVITIS ON CHOROIDAL THICKNESS 237

Table 1. Demographics Study group Control group p Gender n (%) boy 17 16 0.74 girl 13 14 Age mean (years) 12 ± 3.5 11,5 ± 4,1 0.48

Table 2. Subfoveal choroidal thickness value Allergic conjunctivitis Allergic conjunctivitis Control group - no treatment - Post treatment P value (Group3) (Group 1) (Group 2) Subfoveal *0.04 1 > 2 Choroidal 364.1 ± 63.8 333.5 ± 52.1 320.6 ± 80.9 **0.039 1 > 3 Thickness (ìm) ***0.1892=3

* (Paired sample t test) between baseline and after one month treatment values. ** (Student t test) between baseline and control group *** (Student t test) between control group an done month after treatment values. The mean age of study and control groups were 12.4 ± ness between allergic patients and healthy con- 3.5 years and 11.5 ± 4.1 years, respectively. The groups trols. The mean sub-foveal choroidal thickness was were similar in terms of age and gender (p = 0.48, p = 367.49 ± 92.73 mm in patients with and 0.74) (Table 1). the mean sub-foveal choroidal thickness in patients Sub-foveal choroidal thickness was 364.1±63.8 without allergic rhinitis was 327.62 ± 72.39 mm. In par- mm in the allergic conjunctivitis group; the first-month allel with our study, they found this difference was sta- mean values after the treatment were 333.5 ± 52.1 mm. tistically significant (18). Previous studies indicated Sub-foveal choroidal thickness means value in the con- that choroidal alterations were determined in several trol group was 320.6 ± 80.9. There was a statistically ocular or systemic diseases associated with inflamma- significant decrease in mean ChT value after treatment tion. In two adult patients with posterior sclerosis, cho- of allergic conjunctivitis patients (paired sample t-test; roidal thickness measured by OCT was found thicke- p = 0.04) and there was a significant difference betwe- ned in the active phase of the disorder and thinned after en baseline ChT values of allergic conjunctivitis group treatment. The authors suggested that recurrent inflam- and control group (student t-test; p = 0.039). There was mation of the could induce atrophic changes. In no significant difference between one-month values two different studies from the Far East, sub-foveal cho- after treatment and mean values of the control group roidal thickness measured by EDI-OCT of patients (student t-test; p = 0.189) (Table 2). When the choroi- with posterior due to Behçet’s disease was in- dal thickness of children and adolescents with allergic creased in the acute phase of the disease and decreased conjunctivitis were compared according to gender, the after the relief of the acute phase. They showed sub-fo- choroidal thickness of boys was found to be higher veal choroidal thickness was correlated with retinal vas- than girls. However, this difference was not statisti- cular leakage revealed by fluorescein angiography (12, cally significant (p = 0.357). 19). In a case report presents a patient diagnosed with sarcoidosis and having unilateral, multifocal choroidal DISCUSSION AND CONCLUSION granuloma, it was revealed that choroidal thickness dec- In this study, we investigated whether there is any reased by steroid treatment (20). In another study exam- difference in terms of choroidal thickness in children ining choroidal changes in toxoplasma cases with reti- and adolescents with acute allergic conjunctivitis. We no-choroidal lesions, it was found that choroidal thick- also examined the effect of conservative and medical ness was higher in the acute phase of the disease and treatment on choroidal thickness in children with aller- was determined normally in the follow-up (21). gic conjunctivitis.The baseline ChT values of the study Another finding in our study was that boys had group were significantly higher than the control group. higher choroidal thickness than girls. However, this And there was a statistically significant decrease in ChT difference was not statistically significant. In a study of children and adolescents with allergic conjunctivitis from Denmark, the sub-foveal choroidal thickness of after treatment with topical antihistamine agents. 1323 healthy children aged 11 to 12 years was measu- In a study conducted by Yenigun et al. evaluated red by using EDI-OCT. It has been determined that whether there were any differences in choroidal thick- the sub-foveal choroidal thickness was higher in fe- 238 Ayyildiz Taha,Yilmaz Mevlut, Ayyildiz Didem males than in males but the difference wasn’t signifi- Acknowledgment: None cant (22). In our study, the sample size was small, so studies Conflict of Interests: The authors declare that with a larger sample are needed to confirm our findings there are no conflicts of interest related to this article. and to fully clarify the mechanism of increased choroi- Funding: This research did not receive any speci- dal thickness with allergic conjunctivitis. To track al- fic grant from funding agencies in the public, commer- lergic conjunctivitis activity and evaluate the effective- cial, or not-for-profit sectors. ness of the treatment, choroidal thickness measures can be utilized. Authorship Statement: TA, DA wrote the manu- script. TA, MY designed the study, TA, DA and MY Abbreviations contributed to data collection. TA and DA performed ChT — choroidal thickness the statistical analysis and interpretation of the results. CSCR — central serous chorioretinopathy All authors read and approved the final manuscript. CNS — central nervous system SD-OCT — Spectral Optical Coherence Tomog- Licensing raphy EDI OCT — enhanced depth imaging spec- This work is licensed under a Creative Commons tral-domain optical coherence tomography Attribution 4.0 International (CC BY 4.0) License.

Sa`etak UTICAJ ALERGIJSKOG KONJUKTIVITISANA DEBLJINU HOROIDEE Ayyildiz Taha,1 Yilmaz Mevlut,2 Ayyildiz Didem3 1 Kærsehir Ahi Evran University, Faculty of Medicine, Ophthalmology Department, Kærsehir, Turkey 2 Turkey Kærsehir Ahi Evran University, Faculty of Medicine, Ophthalmology Department, Kærsehir, Turkey 3 Kærsehir Ahi Evran University, Training and Research Hospital, Child and Adolescent Psychiatry Department, Kærsehir, Turkey Cilj: Ispitati efekte alergijskog konjunktivitisa i seca tretmana bila je 333.5 ± 52.1 mm. Srednja vred- njegovog le~enja kori{}enjem topikalnih antihistamin- nost subfovealne horoidalne debljine u kontrolnoj gru- skih lekova na debljinu horoidee (ChT). pi bila je 320.6 ± 80.9 mm. Do{lo je do zna~ajnog sma- Metode: U istra`ivanju je u~estvovalo 30 dece i njenja ChT nakon le~enja pacijenata sa alergijskim adolescenata sa alergijskim konjunktivitisom kao i 30 konjunktivitisom i postojala je statisti~ki zna~ajna raz- zdravih kontrola. Kriterijumi za uklju~ivanje pacijena- lika u odnosu na po~etne vrednosti ChT izme|u grupe ta u istra`ivanje bili su najbolja korigovana vidna o{tri- sa alergijskim konjunktivitisom i kontrolne grupe. Nije na 20/20 ili bolje, normalan intraokularni pritisak bilo zna~ajne razlike izme|u srednjih vrednosti ChT (IOP), i odsustvo sistemskih ili drugih o~nih bolesti nakon jednomese~nog le~enja i srednjih vrednosti kon- osim alergijskog konjunktivitisa. Zdrave kontrole su trolne grupe. podrazumevale decu i adolescente bez o~nih ili hro- Zaklju~ak: Na{i rezultati pokazuju da ChT mo`e ni~nih sistemskih bolesti i koji su imali najbolju kori- porasti kod pacijenata sa alergijskim konjunktivitisom govanu vidnu o{trinu 20/20 ili bolje i normalan IOP. i ponovo mo`e postati normalna usled lokalnog le~enja ChT je merena pomocu EDI-OCT (Enhanced Depth antihistaminicima. Kako bi se podr`alo to da horoidal- Imaging Optical Coherence Tomography) pre i posle na debljina bude marker za dijagnozu i pra}enje aler- tretmana antihistaminicima. gijskog konjunktivitisa, dodatna istra`ivanja sa ve}im Rezultati: Srednja vrednost subfovealne horoi- uzorcima i longitudinalne studije su potrebne. dalne debljine bila je 364.1 ± 63.8 mm u grupi sa aler- Klju~ne re~i: alergijski konjunktivitis, antihista- gijskim konjunktivitisom, a vrednost nakon prvog me- min, horoidalna debljina, topikalne kapi za o~i, le~enje.

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Correspondence to/Autor za korespondenciju Mevlut Yælmaz, Assistant Professor Turkey Kær§ehir Ahi Evran University Faculty of Medicine, Ophthalmology Department, Turkey Email: drmevlutyilmazªgmail.com Telephone: 00905557720767