An educational program of: Allergic Conjunctivitis Revised guidelines June 2003

an educational program of:

Allergic ConjunctivitisRevised guidelines June 2003

Slide 2

GLORIA resource documents

Allergic Conjunctivitis: Assessment and Therapy

• World Allergy Organization-IAACI 2003

Contemporary Approaches to Ocular Allergy Management

• American College of Allergy, Asthma and Immunology 1998

World Allergy Forum Program Series

• World Allergy Organization 2000-2003

Slide 3

Revised Nomenclature of Allergic Disease

Intermittent – occasional symptoms lasting < 4 days per week on ≤ 4 weeks

Persistent – symptoms lasting > 4 days per week or > 4 weeks

Slide 4

Allergic Conjunctivitis

A broad group of allergic conditions involving inflammation of the conjunctiva• Acute Allergic Conjunctivitis (AAC)• Intermittent/Seasonal Allergic Conjunctivitis

(IAC/SAC)• Persistent/Perennial Allergic Conjunctivitis (PAC)• Giant Papillary Conjunctivitis (GPC)• Vernal Keratoconjunctivitis (VKC)• Atopic Keratoconjunctivitis (AKC)

Slide 5

The Conjunctiva

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

Slide 6

Allergic conjunctivitis: Epidemiology

Acute Allergic Conjunctivitis (AAC)

• Occurs at any age, especially childhood

Intermittent/Seasonal Allergic Conjunctivitis (IAC/SAC)

• Affects 5% to 22% of the general population

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Persistent/Perennial Allergic Conjunctivitis (PAC)

• Found in 4% of patients attending an inner city health center during summer months, USA Dart et al, 1986

Giant Papillary Conjunctivitis (GPC)

• 1 - 5% of rigid gas permeable contact lens wearers; 10-15% of hydrogel (soft) contact lens wearers, USA Abelson, 2000

Slide 8


Vernal Keratoconjunctivitis (VKC)

• Pre-pubescent boys in warm, dry climate

• 10% of all eye patients in East Jerusalem, O’Shea, 2000

• 0.5-1.0% of all patients in eye clinics worldwide, Beigelman, 1950

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Atopic Keratoconjunctivitis (AKC)

• Atopic Eczema/Dermatitis Syndrome affects 3% of US population; 15-40% of AEDS patients develop AKC.

• Occurs 2nd through 5th decade, males more often affected than females

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The normal eyelid and conjunctiva

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Allergic conjunctivitis: Major symptoms

Pronounced itching

Watery, stringy or ropy discharge

Redness

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Diagnosis of allergic conjunctivitis

Detailed personal and family allergic history and physical examination

History of typical eye symptoms

Appearance of everted (flipped) eyelid

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Examination of surface of the eye

The surface markings of the conjunctiva extend beyond the visible limits of the eye

Slide 14

The everted eyelid

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Diagnosis of allergic conjunctivitis: Clinical investigations

Allergy skin tests performed by an allergist

and/or

Measurement of allergen specific IgE antibody (Radioallergosorbent tests)

Conjunctival scrapings for eosinophils – particularly elevated in VKC, AKC and GPC

Conjunctival challenge

Slide 16

Differential diagnosis of allergic conjunctivitis

Acute Allergic Conjunctivitis (AAC) occurs at any age, especially childhood

Large quantity of allergen (eg, plant pollen) inoculated into eye causes:

• Intense itching

• Immediate swelling of conjunctiva and lids (eye may close)

Self-limiting

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Acute allergic conjunctivitis

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Intermittent/Seasonal Allergic Conjunctivitis (IAC/SAC)

Persistent/Perennial Allergic Conjunctivitis (PAC)

• Related to seasonal or perennial allergens, association with genetic predisposition to allergic rhinitis

Slide 19

Everted eyelid in intermittent/seasonal allergic conjunctivitis

Slide 20

Persistent/perennial allergic conjunctivitis

Slide 21

‘Allergic Shiners’

Fireman P, Atlas of Allergies, 1996

Slide 22

Giant Papillary Conjunctivitis (GPC)

• Trauma due to contact lens, ocular prosthesis, aggravated by concomitant allergy


Slide 23

The upper tarsal conjunctiva in giant papillary conjunctivitis

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Vernal Keratoconjunctivitis

• A disease of childhood sometimes associated with atopic constitution.

Severe T-cell mediated disease involving the cornea: may be sight-threatening

Slide 25

Conjunctival appearance in vernal keratoconjunctivitis

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Atopic Keratoconjunctivitis• A persistent disease of the eyelids usually

beginning in young adulthood. Associated with the atopic eczema/dermatitis syndrome (AEDS) infection, corneal thinning, cataracts and environmental allergens.


Severe T-cell mediated disease involving the cornea: may be sight-threatening

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The eye and periorbital region in atopic keratoconjunctivitis

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Corneal changes in atopic keratoconjunctivitis

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Simple differential diagnosis of allergic conjunctivitis and other conditions

If it itches, it is allergy;

if it burns, it is probably dry eye;

if the eyelids are stuck together in the

morning, it is a bacterial infection.

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Globally important allergens

House dust mites

Grass, tree and weed pollen

Pets

Cockroaches

Molds

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Clinical investigations: Allergy skin prick testing

Skin prick test / positive result

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Laboratory investigations: Radioallergosorbent tests

Slide 33

Different cell types infiltrate the conjunctiva

AAC, IAC, SAC, PAC

• Mast cells

• Eosinophils

• Neutrophils

GPC, VKC, AKC

• T cells

• Eosinophils

• Mast Cells

• Neutrophils

Slide 34

Mediators of the IgE-mediated reaction in allergic conjunctivitis

Chemotactic factors from eosinophils and neutrophils cell destruction, disruption of ocular surface.

Leukotrienes chemotaxis, edema and vascular permeability

Prostaglandins sensitized nerves, enhanced pain, edema and redness

Histamine itching, redness and edema

Slide 35

Modes and sites of action of allergic conjunctivitis therapies

Mast cell

B cell

T cell

(mast cell) Eosinophil

IL-4

IL-3, -5

GM-CSF

VCAM-1

IgE

Immediate symptoms• Itch, redness, edema,chemotaxis, edema, vascular permeability

•Sensitized nerves, enhanced pain, edema, redness

Chronic symptoms•cell destruction

•disruption of ocular surface

HistamineLeukotrienesProstaglandins

Allergen

Allergen avoidance

Immuno-therapy

AntihistaminesOlopatadine

Sodium cromoglycateOlopatadine

Steroids

Eosinophil and Neutrophil chemotactic factors:

Anti-IgE

Slide 36

Treatment of allergic conjunctivitis: Allergen avoidance

Allergen avoidance and environmental control

are the

first steps in the

management of allergic disease

Slide 37

Treatment of allergic conjunctivitis: Allergen avoidanceHouse dust mites:

• Provide adequate ventilation todecrease humidity

• Wash bedding regularly at 60°C• Encase pillow, mattress and quilt in allergen

impermeable covers• Dispose of feather bedding • Use vacuum cleaner with HEPA filter (when available)• Replace carpets with linoleum or wooden floors• Remove curtains, pets and stuffed toys from bedroom• Provide adequate ventilation to decrease humidity

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Pollen

• Very difficult to avoid!

• Remain indoors with windows closed at peak pollen times

• Wear sunglasses and hat outdoors

• Use air-conditioning, where possible

• Install car pollen filter

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Pet Allergens

• Exclude pets from bedrooms and, where possible, from home

• Vacuum carpets, mattresses and upholstery regularly

• Wash pets regularly

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Cockroach Allergens

• Eradicate cockroaches with appropriate insecticide

• Eliminate dampness, cracks in floors, ceilings, cover food; wash surfaces, floors, fabrics to remove allergen

© 1998-2003 Troy Bartlett

Slide 41

Molds

• Ensure dry housing

• Use ammonia to remove mold from bathrooms and other wet spaces


Slide 42

Treatment of allergic conjunctivitis:Non-pharmacological therapy

Allergen avoidance including physical barriers, eg, hat, sunglasses, allergen-impermeable pillow and mattress covers

Cold compresses

Preservative-free tears

Slide 43

Topical NSAIDs

• Ketorolac – of limited effectiveness

Vasoconstrictors

• Not recommended for regular use

Pharmacotherapy of allergic conjunctivitis:Topical NSAIDs, Vasoconstrictors

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Pharmacotherapy of allergic conjunctivitis: Topical antihistamines

Topical antihistamines

• azelastine, emedastine, levocabastine

Topical antihistamine plus vasoconstrictor

• antazoline-naphazoline, cetirizine-pseudoephedrine, pheniramine-naphazoline

Slide 45

Pharmacotherapy of allergic conjunctivitis

Once daily administration

Rapid onset and 24 hour duration of action

No sedation

No interaction with alcohol, foods, drugs

Additive anti-allergic activities

Properties required of ideal new generation oral antihistamines

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Pharmacotherapy of allergic conjunctivitis: Oral antihistamines

Less effective than topical therapies

Beware unwanted effects of ‘dry eye’

If indicated for multiple allergic symptomatology, select non-sedating oral antihistamines:

loratadine, fexofenadine, cetirizine

Slide 47

Pharmacotherapy of allergic conjunctivitis: Topical mast cell stabilizers

Preventative: Do not work immediately

DSCG: Debatable effectiveness

Nedocromil: Twice daily

Lodoxamide: Highly potent, rapid relief, additional anti-eosinophilic effect

Pemirolast: Twice or four times daily dosing, effective for itch

Slide 48

Pharmacotherapy of allergic conjunctivitis: Dual-action antihistamine/mast cell stabilizer

Olopatadine: Highly effective, comfortable

Ketotifen: Approved for itch

Azelastine: Approved for itch

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Pharmacotherapy of allergic conjunctivitis: Topical corticosteroids

Topical corticosteroid therapy must be prescribed and monitored, preferably by an ophthalmologist because:

• It is only appropriate for treatment of severe allergic ocular disease – not for intermittent/seasonal allergic conjunctivitis

• Prolonged use can lead to secondary bacterial infection, glaucoma and cataracts

Slide 50

Pharmacotherapy of allergic conjunctivitis: Specific allergen immunotherapy (allergen vaccination)

Must be administered by allergy specialist centre with resuscitation facilities

Helpful in managing persistent allergic rhinitis and atopic keratoconjunctivitis

Of value in patients with multi-organ symptoms of IgE-mediated allergic sensitization

Risk-to-benefit ratio must be considered in all cases

Highly effective in selected patients

Slide 51

Pharmacotherapy guidelines for persistent/perennial allergic conjunctivitis

Topical mast cell stabilizer, or

Dual action antihistamine/ mast cell stabilizer

Consider immunotherapy/ vaccination at specialist center

Step 1

Step 2

Slide 52

Pharmacotherapy guidelines for intermittent/seasonal allergic conjunctivitis

Topical antihistamine and/or topical NSAID

Step 1

Step 2

Step 3

Topical antihistamine with vasoconstrictors

Dual action antihistamine/mast cell stabilizer

Therapy may be increased in a step-wise fashion until adequate control is achieved, or commenced at Step 3

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Pharmacotherapy of allergic disease: Future directions – Anti IgE

>75% of allergic asthmatics have rhinitis; >40% of allergic rhinitis patients have allergic conjunctivitis

Humanized monoclonal antibodies against IgE, e.g., omalizumab are effective for treatment of moderate to severe asthma. Such therapy:

(cont’d on next slide)

Slide 54

• Decreases free IgE levels and down-regulates IgE receptors on basophils

• Inhibits the late phase allergic reaction following allergen bronchial challenge

• Preliminary study indicates omalizumab is effective for nasal and ophthalmic symptoms of intermittent and perennial allergic rhinitis

• Ongoing studies to determine the effect of omalizumab in atopic dermatitis may have implications for treatment of AKC

Pharmacotherapy of allergic disease: Future directions- Anti IgE, cont’d.

Slide 55

Persistent or worsening ocular allergy

Persistent or worsening eye symptoms not responsive

to therapy are an indication for urgent referral to a

physician who specializes in allergic eye disease.

Documents

An educational program of: Allergic Conjunctivitis Revised guidelines June 2003