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OCULAR ALLERGY CCDH MEETING MARCH 2014 Dr Michael Minogue

Ocular Allergy

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Ocular Allergies- Classification, Signs and symptoms, Pathogenesis, Treatment,

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Page 1: Ocular Allergy

OCULAR ALLERGYCCDH MEETING

MARCH 2014

Dr Michael Minogue

Page 2: Ocular Allergy

CLASSIFICATION

acute conjunctival allergy seasonal allergic conjunctivitis perennial allergic conjunctivitis vernal kerato-conjunctivis atopic kerato-conjunctivis giant papillary conjunctivitis contact allergic conjunctivis

Page 3: Ocular Allergy

SYMPTOMS

itch conjunctival hyperaemia tearing conjunctival oedema mucus discharge lid oedema photophobia eye rubbing blurred vision

Page 4: Ocular Allergy

SEASONAL ALLERGIC CONJUNCTIVITIS

sub-acute onset lasts days to weeks seasonal allergens- grass, tree pollens, moulds associated with hay-fever/allergic rhinitis IgE mediated, type 1 allergic response 80% of patients are under 30 years of age strong personal or family history of allergy affects 5 to 20% of population

Page 5: Ocular Allergy

Cytokine regulation of the acquired immune response

Page 6: Ocular Allergy
Page 7: Ocular Allergy

ACUTE CONJUNCTIVAL ALLERGY

sudden onset eg allergy to cats self limited- usually settles within 24hrs conjunctival and lid oedema can be alarming

to patient

Page 8: Ocular Allergy

PERENNIAL ALLERGIC CONJUNCTIVIS

persistent symptoms but can have seasonal spikes

triggered by house-dust mites,moulds,animal allergens

IgE mediated mostly young adults (slightly higher prevalence

in males often personal or family history of allergy

Page 9: Ocular Allergy

VERNAL KERATOCONJUNCTIVITIS

a disease with some allergic components in combination with a chronic inflammatory response

comprises 2% of cases of ocular allergy mostly affects young boys under 10 years of

age most common in hot climates tarsal (cobblestone papillae) and limbal

(trantas dots) variants personal or family history of atopy in 50% positive skin test in only 50%

Page 10: Ocular Allergy

Upper tarsal conjunctiva of patient with VKC

Page 11: Ocular Allergy

PATHOPHYSIOLOGY

1. Th2 lymphocytes mediate hyperproduction of IgE via Il4 . They also mediate differentiation and activation of mast cells and eosinophils via Il3 and Il5 respectively.

2. Over-expression of oestrogen and progesterone receptors in the conjunctiva of VKC patients may explain improvement with onset of puberty.

3. There may be involvement of neural factors such as substance P and NGF in pathogenesis

4. Hypersensitivity to wind, dust, sun may have a role.

5. Probable genetic component - a reduced level of tear film histaminase has been found.

Page 12: Ocular Allergy

CLINICAL FEATURES OF VKC

giant papillae/ trantas dots ropy mucus discharge common SPK and shield ulcers may be related to

epithelial toxic effects of eosinophilic major basic protein, eosinophilic cationic protein and peroxidase

ptosis can occur steroid induced glaucoma and cataract can

occur

Page 13: Ocular Allergy

ATOPIC KERATOCONJUNCTIVITIS

associated with atopic eczema often periocular with lid margin involvement male predominance, age 30-50 often strong family history of allergy (atopic

eczema an asthma) can have associated ocular surface disease

(conjunctival scarring, corneal PEK, corneal vascularization)

herpetic keratitis can occur in 15% of patients

keratoconus can occur in 5-15% of patients affects 3% of population

Page 14: Ocular Allergy

Severe periocular and lid involvement of AKC

Page 15: Ocular Allergy

ATOPIC KERATO-CONJUNCTIVITIS (CONT.)

eyelid skin thickened with lichenification can have associated punctal ectropion/ ptosis lower fornix conjunctival papillae potential visual loss from corneal disease,

cataract, steroid, induced glaucoma type I and type IV hypersensitivity increased mast cells, eosinophils, CD4+ T cells

(Th1 and Th2), monocytes, fibroblasts

Page 16: Ocular Allergy

Limbal gelatinous hyperplasia in AKC

Page 17: Ocular Allergy

GIANT PAPILLARY CONJUNCTIVITIS

non infectious inflammation disorder of the superior tarsal conjunctiva

named for size of papillae (> 1mm in diameter)

papillae > 0.3 mm are considered abnormal occurrence 1 to 5% of soft contact lens

wearers, 1% of hard contact lens wearers average time of onset is 8 months for soft

contact lens wearers can occur secondary to exposed sutures,

elevated subepithelial calcium plaques, ocular prosthetics

often associated history of atopy

Page 18: Ocular Allergy

Giant papillary conjunctivitis Advancing conjunctival thickening and papillary formation

Giant papillae

Page 19: Ocular Allergy

SYMPTOMS AND SIGNS

early - mild irritation, scanty mucus discharge

late - blurred vision secondary to lens coating

with mucus and protein - increased mucus accumulation - persistent protein body sensation - ocular itching after contact lens removal - complete contact lens intolerance

Page 20: Ocular Allergy

PATHOGENESIS

probably due to combined effect of mechanical trauma followed by repeated immunological presentation of foreign antigens in the form of surface deposits or environmental agents

combined type I and type IV hypersensitivity reactions

infiltration of conjunctival substantia propria by eosinophils, mast cells (T cell independent, skin type), basophils, lymphocytes and plasma cells

Page 21: Ocular Allergy

TREATMENT

removal of cause change to daily wear contact lenses of RGP

lenses hydrogen peroxide disinfection probably best more frequent enzymatic cleaning of soft

lenses topical corticosteroid in acute phase (along

with contact lens discontinuation) good prognosis

Page 22: Ocular Allergy

TREATMENT

1. non specific allergen avoidance air conditioning cold compresses cold artificial tears

2. topical or oral antihistamines eg OTC Naphazoline-Antazoline

3. combined antihistamine / mast cell stabilizers Olapatadine (Patanol)- preservative BAK Ketotifen (Zaditen) – preservative free

4. mast cell stabilizers Cromoglycate (Opticrom) Lodoxamide (Lomide)

Page 23: Ocular Allergy

TREATMENT (CONT.)

5. topical steroid FML Maxidex Prednefrin Forte

6. calcineurin inhibitors Cyclosporine (Restasis) Tacrolimus

7. systemic immuno supression oral Prednisone oral Cyclosporine

8. Plasmapheresis

Page 24: Ocular Allergy

QUESTIONS1. Which of the following symptoms is associated with ocular allergy?

a. itch

b. tearing

c. conjunctival hyperaemia

d. all of the above

2. Which of the following drug is not generally used in the treatment of

conjuctival allergy?

e. topical antihistamine / mast cell stabilizer

f. topical steroid

g. topical calcineurin inhibitors

h. NSAIDS

3. Which of the following can be associated with AKC and VKC?

i. keratoconus

j. bacterial keratitis

k. glaucoma

l. cataract

m. all of the above