Allergic Eye Disease. Rhian H. Grötte Paediatric Ophthalmology Red Cross Children s Hospital and UCT
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1 Allergic Eye Disease Rhian H. Grötte Paediatric Ophthalmology Red Cross Children s Hospital and UCT
2 External eye infections are the commonest reason for referral to primary eye health clinics. Allergic eye disease is the commonest reason for chronic red eyes not responsive to antibiotics.
3 Simple Differential Diagnosis If it itches it is allergy If it burns it is dry eye If the eyelids are stuck together in the morning it is infection
4 Ocular allergic diseases Ocular allergies affect approximately 15 20% of the population worldwide 90% of allergic disorders seen by an allergist have an ocular component 93% of hay fever sufferers have ocular symptoms
5 The surface of the eye is the most obviously exposed mucous membrane of the body The conjunctival surface is accessible to allergens and is the site of allergic reactions
6 Stem Cell Prelymphocyte Lymphocyte Thymus B lymphoctes Plasmacell IgG, IgA, IgM, IgD, IgE antibodies T Lymphocytes Helper T cells Th Suppressor T cells Ts Cytotoxic T cells Tc Lymphokine producing cells Tdh
7 Giant papillary conjunctivitis ( GPC) (associated with contact lens wear) Classification of ocular allergy Ocular urticaria / Acute allergic conjunctivitis (AAC) Allergic conjunctivitis seasonal (SAC ) and perennial (PAC) Vernal keratoconjunctivitis (VKC) Atopic keratoconjunctivitis (AKC)
8 Ocular Urticaria Acute Allergic Conjunctivitis Caused by a sudden big dose of air borne or hand borne allergen
9 Acute allergic conjunctivitis
10 Seasonal/perennial allergic conjunctivitis Hyperemia Eyelid swelling Chemosis Papillary reaction
11 Allergic Rhinoconjunctivitis Allergens react with IgE antibodies bound to conjunctival mast cells
12 Allergic rhinoconjunctivitis Seasonal Occurs in spring, autumn, or both Grass, tree pollen, Early- and late-phase IgE reactions Perennial Year round with more pronounced periods Animal dander, dust mites, mould, spores History of other atopic diseases Early- and late-phase IgE reactions
13 Signs and symptoms of allergic conjunctivitis Seasonal Itching (ocular and periocular) Redness Burning Excessive tearing Stringy white mucus Rhinitis Perennial Similar to seasonal allergic conjunctivitis Milder than seasonal allergic conjunctivitis More constant than seasonal allergic conjunctivitis Seasonal exacerbations
14 Type I hypersensitivity reaction Acute or seasonal allergic conjunctivitis is a type I hypersensitivity reaction The sequence of events involved in a type I hypersensitivity reaction can be divided into three phases Sensitization phase Activation phase (early allergic response) Late allergic response
15 Allergic sensitization Allergen in tears (1 st exposure) Conjunctival epithelium B lymphocyte Major Histocompatibility Complex IL-4 IL-13 IL-5 IL-6 IgE antibodies T lymphocyte Plasma cell Antigen-presenting cell Sensitized mast cell From Lichtenstein LM. Allergy and the immune system. Scientific Am. 1993; 269:
16 The early allergic response Allergen in tears (2 nd exposure) Conjunctival epithelium ECF-A Histamine Heparin Chymase Tryptase Eosinophil Blood vessel Activated mast cell Newly synthesized Leukotrienes Prostaglandins Cytokines PAF Basophil Histamine releasing factor From Lichtenstein LM. Allergy and the immune system. Scientific Am. 1993; 269:
17 The late allergic response Activated mast cell Leukotrienes Cytokines Eosinophil Blood vessel Prostaglandins Histamine Basophil Lipids Chemokines Cytokines From Lichtenstein LM. Allergy and the immune system. Scientific Am. 1993; 269:
18 Management options for allergic conjunctivitis Simple non pharmacological remedies Oral Anthistamines Topical pharmacological treatment
19 Simple Non-Pharmacological Allergen avoidance Pet control Use air conditioning Remedies Avoid outdoor activities during high pollen periods Cold compresses Lubricating eye drops
20 Treatment Options for Allergic Conjunctivitis Oral Antihistamines loratadine (Clarityne 10mg) fexofenodine (Telfast 120mg) cetirizine (Zyrtec 10mg)
21 Topical Pharmacological Treatment of Allergic Conjunctivitis Vasoconstrictors Antihistamines Mast cell stabilisers Non steroidal anti-inflammatory drugs Corticosteroids
22 Topical Antihistamines and Vasoconstrictors Vasoconstrictors alone, phenylephrine, naphazoline oxymetazoline, tetryzoline (Oxylin, Prefrin,Safyr Bleu ) Antihistamines with Vasoconstrictors Antazoline / naphazoline (Antistin-Privine) Tetryzoline / Antazoline ( Spersallerg)
23 Longer Acting Antihistamines Emedastine Levocabastine (Emedine) (Livostin ED) Convenient twice a day dosage
24 Mast Cell Stabilisers Sodium Cromoglycate (Opticrom, Cromohexal, Stop-Allerg, Vividrin) 4 times a day dosage Long term benefit, not immediate relief Stings
25 Mast Cell Stabiliser with Antihistamine Effect Olopatadine ( Patanol) Convenient 2x day dosage Immediate relief of itch
26 Mast cell Stabiliser with Antihistamine and Anti- eosinophil effects Ketotifen (Zaditen) Convenient 2x day dosage
27 Non- steroidal Anti-inflammatory Drugs Diclofenac Flurbiprofen Ketorolac ( Voltaren) (Ocufen) ( Acular) Anti-prostaglandin effect 3 or 4 x a day dosage
28 Giant papillary conjunctivitis ( GPC) (associated with contact lens wear) Classification of ocular allergy Ocular urticaria / Acute allergic conjunctivitis (AAC) Allergic conjunctivitis seasonal (SAC ) and perennial (PAC) Vernal keratoconjunctivitis (VKC) Atopic keratoconjunctivitis (AKC)
29 Vernal conjunctivitis and atopic conjunctivitis differ from simple allergic conjunctivits because they involve a cell mediated immune reaction much more severe signs have sight threatening complications.
30 Epidemiology of Vernal Keratoconjunctivits Pre-pubescent boys in warm dry climates 10% of all eye patients in East Jerusalem O Shea % of all patients in eye clinics worldwide Beigelmann 1950
31 Vernal Keratoconjunctivitis Severe bilateral chronic recurrent ocular inflammation Intense itch Copious lardaceous stringy discharge Starts pre-school Burns out years later Usually lasts from September until Easter in Cape Town Maybe the only allergic manifestation
32 Vernal Keratoconjunctivitis (Spring catarrh) Limbal Type (black patients) Palpebral Type (white patients)
33 Limbal Type Vernal Conjunctivitis
34 Limbal Type Vernal Conjunctivitis
35 Limbal Type Vernal Conjunctivitis Mucoid nodule Tranta's dots
36 Resolved limbal infiltration Inactive limbal infiltration
37 Tarsal papillae (cobblestones) in white (palpebral) type vernal conjunctivitis
38 Palpebral Type Vernal Conjunctivitis Diffuse papillary hypertrophy on the upper tarsus
39 Corneal Complications in Vernal Conjunctivitis Punctate Keratitis
40 Corneal Complications in Vernal Conjunctivitis Epithelial macroerosion
41 Corneal Complication in Vernal Conjunctivitis Plaque formation ( Shield Ulcer)
42 Corneal Complications in Vernal Conjunctivitis Permanent subepithelial scarring
43 The Aetiology of Vernal Conjunctivitis Only 50% have +ve skin tests IgE raised in serum but not in tears A complex non IgE dependent pathological mechanism involving Th2 immune lymphocytes
44 The aetiology of Vernal Keratoconjunctivitis A Th2 driven mechanism Multitude of cells and mediators detected eosinophilic mediators Arachidonic acid derived mediators prostaglandins, leukotrienes Substance P (a neuropeptide) raised increased oestrogen and progesterone receptors
45 Atopic keratoconjunctivitis Affects young patients with atopic dermatitis Eyelids are red thickened Macerated and fissured
46 Atopic keratoconjunctivitis Palpebral eczema associated with dermatitis Corneal neovascularization with oedema
47 Atopic Conjunctivitis Infiltration of tarsal conjunctiva causing featureless appearance
48 Atopic Conjunctivitis Often progresses to tarsal papillae ( cobblestones)
49 Corneal complications in atopic conjunctivitis Punctate epithelialopathy Plaque formation Corneal Scarring Corneal Vascularisation
50 Giant papillary Conjunctivitis The upper tarsal conjunciva in giant papillary conjunctivitis
51 Different cell types infiltrate the conjunctiva AAC SAC PAC VKC AKC GPC Mast cells Eosinophils Neutrophils T cells Eosinophils Mast cells Neutrophils
52 Treatment of Vernal Keratoconjunctivitis Mast cell Stabilising Eye drops +/- Steroid Eyedrops
53 The Old Gold Standard G. Cromoglycate QID + G. Fluoromethalone QID +/- Oc. Dexamethazone nocte
54 The New Approach G. Ketotifen bd + G. Fluoromethalone bd OR G. Olopatidine + G. Fluoromethalone bd + Oc. Dexamethozone nocte
55 Treatment of Vernal Keratoconjunctivitis in the Future Inhibition of the Th2 immune cell response Tacrolimus more promising than cyclosporine
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