Transcript In allergic rhinoconjunctivitis, swollen, pigmented

Allergic Conjunctivitis
Revised guidelines June 2003
an educational program of:
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 2
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 3
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 4
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 5
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
Slide 6
Allergic conjunctivitis: Epidemiology
 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 7
Allergic conjunctivitis: Epidemiology
 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
Slide 8
Allergic conjunctivitis: Epidemiology
 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
Slide 9
The normal eyelid and conjunctiva
Slide 10
Allergic conjunctivitis: Major symptoms
 Pronounced itching
 Watery, stringy or ropy discharge
 Redness
Slide 11
Diagnosis of allergic conjunctivitis
 Detailed personal and family allergic history and
physical examination
 History of typical eye symptoms
 Appearance of everted (flipped) eyelid
Slide 12
Examination of surface of the eye
 The surface markings of the conjunctiva extend
beyond the visible limits of the eye
Slide 13
The everted eyelid
Slide 14
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 15
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
Slide 16
Acute allergic conjunctivitis
Slide 17
Differential diagnosis of allergic
conjunctivitis
 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 18
Everted eyelid in intermittent/seasonal
allergic conjunctivitis
Slide 19
Persistent/perennial allergic conjunctivitis
Slide 20
‘Allergic Shiners’
Fireman P, Atlas of Allergies, 1996
Slide 21
Differential diagnosis of allergic
conjunctivitis
 Giant Papillary Conjunctivitis (GPC)
• Trauma due to contact lens, ocular prosthesis,
aggravated by concomitant allergy
Slide 22
The upper tarsal conjunctiva in giant
papillary conjunctivitis
Slide 23
Differential diagnosis of allergic
conjunctivitis
 Vernal Keratoconjunctivitis
• A disease of childhood sometimes associated with
atopic constitution.
Severe T-cell mediated disease involving the cornea: may be
sight-threatening
Slide 24
Conjunctival appearance in vernal
keratoconjunctivitis
Slide 25
Differential diagnosis of allergic
conjunctivitis
 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
Slide 26
The eye and periorbital region in atopic
keratoconjunctivitis
Slide 27
Corneal changes in atopic keratoconjunctivitis
Slide 28
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.
Slide 29
Globally important allergens
 House dust mites
 Grass, tree and weed
pollen
 Pets
 Cockroaches
 Molds
Slide 30
Clinical investigations:
Allergy skin prick testing
 Skin prick test / positive result
Slide 31
Laboratory investigations:
Radioallergosorbent tests
Slide 32
Different cell types infiltrate the conjunctiva
 AAC, IAC, SAC, PAC
 GPC, VKC, AKC
• Mast cells
• T cells
• Eosinophils
• Eosinophils
• Neutrophils
• Mast Cells
• Neutrophils
Slide 33
Mediators of the IgE-mediated reaction in
allergic conjunctivitis
Histamine
itching, redness and edema
Prostaglandins
sensitized nerves, enhanced pain, edema and redness
Leukotrienes
chemotaxis, edema and vascular permeability
Chemotactic factors from eosinophils and neutrophils
cell destruction, disruption of ocular surface.
Slide 34
Modes and sites of action of allergic
conjunctivitis therapies
Sodium cromoglycate
Olopatadine
Allergen
avoidance
Mast cell
Anti-IgE
Histamine
Leukotrienes
Prostaglandins
IgE
Allergen
Antihistamines
Olopatadine
Immediate
symptoms
• Itch, redness,
edema,chemotaxis,
edema, vascular
permeability
•Sensitized nerves,
enhanced pain,
edema, redness
B cell
IL-4
VCAM-1
Steroids
Immunotherapy
Slide 35
T cell
(mast cell)
IL-3, -5
Chronic symptoms
Eosinophil
GM-CSF
Eosinophil and Neutrophil
chemotactic factors:
•cell destruction
•disruption of ocular
surface
Treatment of allergic conjunctivitis:
Allergen avoidance
Allergen avoidance and environmental control
are the
first steps in the
management of allergic disease
Slide 36
Treatment of allergic conjunctivitis:
Allergen avoidance
 House dust mites:
• Provide adequate ventilation to
decrease 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
Slide 37
Treatment of allergic conjunctivitis:
Allergen avoidance
 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
Slide 38
Treatment of allergic conjunctivitis:
Allergen avoidance
 Pet Allergens
• Exclude pets from
bedrooms and, where
possible, from home
• Vacuum carpets,
mattresses and
upholstery regularly
• Wash pets regularly
Slide 39
Treatment of allergic conjunctivitis:
Allergen avoidance
 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 40
Treatment of allergic conjunctivitis:
Allergen avoidance
 Molds
• Ensure dry housing
• Use ammonia to remove
mold from bathrooms
and other wet spaces
Slide 41
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 42
Pharmacotherapy of allergic conjunctivitis:
Topical NSAIDs, Vasoconstrictors
 Topical NSAIDs
• Ketorolac – of limited effectiveness
 Vasoconstrictors
• Not recommended for regular use
Slide 43
Pharmacotherapy of allergic conjunctivitis:
Topical antihistamines
 Topical antihistamines
• azelastine, emedastine, levocabastine
 Topical antihistamine plus vasoconstrictor
• antazoline-naphazoline, cetirizinepseudoephedrine, pheniramine-naphazoline
Slide 44
Pharmacotherapy of allergic conjunctivitis
Properties required of ideal new generation
oral antihistamines
 Once daily administration
 Rapid onset and 24 hour duration of action
 No sedation
 No interaction with alcohol, foods, drugs
 Additive anti-allergic activities
Slide 45
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 46
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:
Slide 47
Twice or four times daily dosing,
effective for itch
Pharmacotherapy of allergic conjunctivitis:
Dual-action antihistamine/mast cell stabilizer
 Olopatadine: Highly effective, comfortable
 Ketotifen:
Approved for itch
 Azelastine:
Approved for itch
Slide 48
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 49
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 50
Pharmacotherapy guidelines for
persistent/perennial allergic conjunctivitis
Step 2
Step 1
Topical mast cell
stabilizer, or
Dual action antihistamine/
mast cell stabilizer
Slide 51
Consider
immunotherapy/
vaccination at specialist
center
Pharmacotherapy guidelines for
intermittent/seasonal allergic conjunctivitis
Therapy may be increased in a step-wise
fashion until adequate control is
achieved, or commenced at Step 3
Step 2
Step 1
Topical antihistamine
and/or topical NSAID
Slide 52
Topical
antihistamine with
vasoconstrictors
Step 3
Dual action
antihistamine/mast
cell stabilizer
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 53
Pharmacotherapy of allergic disease:
Future directions- Anti IgE, cont’d.
• 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
Slide 54
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.
Slide 55