INDEPENDENT WORK
DEPARTMENT : OPHTALMOLOGY
DEPARTMENT CHIEF : BILOLOV E.
2013
OCULAR ALLERGIC DISEASE
GROUP : 515
PERFORM BY: AKHMEDOV
SHOXRUKH
CHECKED BY:
SAIDA MAMAJONOVA
TASHKENT 2013
OCULAR ALLERGIC DISEASE
PURPOSE OF REVIEW:
This review will focus on recent advances in our understanding of the pathogenesis of allergic eye
diseases. Common findings in acute allergic conjunctivitis (seasonal and perennial) and chronic
allergic conjunctivitis

vernal keratoconjunctivitis

atopic keratoconjunctivitis

giant papillary conjunctivitis include evidence of mast cell activation and eosinophil attraction
and activation.
Cytokine levels found in tears, conjunctival impression cytology and biopsy specimens, and serum
have been evaluated as markers of disease, and as targets of therapeutic intervention.
RECENT FINDINGS:
Human conjunctival epithelial cells respond to tumor necrosis factor alpha, interleukin-1 beta, and
interferon-gamma individually and in combination. Intracellular adhesion molecule-1 expression is
upregulated by interleukin-1 beta and tumor necrosis factor alpha. Conjunctival epithelial cells
release interleukin-8 in response to interleukin-1 beta and tumor necrosis factor alpha but not
interferon-gamma. Supernatants from activated mast cells cause increased adhesion of eosinophils to
conjunctival epithelium.
Tear levels of tumor necrosis factor alpha were elevated in vernal keratoconjunctivitis patients
compared with normal controls. T cell lines from chronic allergic eye disease patients showed
inconsistent production of cytokines in atopic and vernal keratoconjunctivitis and low levels in giant
papillary conjunctivitis. Vernal keratoconjunctivitis patients have differing levels of eosinophil
cationic protein in their serum if they were serum specific immunoglobulin E positive compared to
serum specific immunoglobulin E negative patients.
Definition
Allergic conjunctivitis
Allergic conjunctivitis, also called "allergic rhinoconjunctivitis," is the most common allergic eye
disorder. The condition is usually seasonal and is associated with hay fever. The main cause is
pollens, although indoor allergens such as dust mites, molds, and dander from household pets such as
cats and dogs may affect the eyes year-round. Typical complaints include itching, redness, tearing,
burning, watery discharge, and eyelid swelling. To a large degree, the acute (initial) symptoms
appear related to histamine release.
The treatments of choice are topical antihistamine drops such as olopatadine (Patanol),
decongestants, and the newer mast-cell stabilizer medications. Topical steroids should be used only if
prescribed by a doctor for severe reactions and on a short-term basis because of the potential for side
effects. In general, oral antihistamines like loratadine (Claritin) or cetirizine (Zyrtec) are the least
effective option, but they are often used for treating allergic rhinitis together with allergic
conjunctivitis.
Rubbing itchy eyes is a natural response. However, rubbing usually worsens the allergic reaction due
to the physical impact on the mast cells, which causes them to release more mediators of the immune
response. Translation: Do not rub your eyes!
Conjunctivitis with atopic dermatitis
Commonly called "atopic keratoconjunctivitis," this condition is a notorious cause of severe eye
changes, particularly in young adults. Atopic keratoconjunctivitis implies inflammation of both the
conjunctiva and cornea. "Kerato" means pertaining to the cornea. This form of conjunctivitis usually
affects adolescent boys (three times more frequently than girls) and is more common in those who
had atopic dermatitis in early childhood. The condition is characterized by intensely itchy, red areas
that appear on the eyelids. A heavy discharge from the eyes can occur, and the skin of the eyelid may
show scales and crusts. In severe cases, the eyes become sensitive to light, and the eyelids noticeably
thicken. If managed poorly, there can be permanent scarring of the cornea due to chronic rubbing and
scratching of the eyes. This scarring can cause visual changes.
The triggers for atopic keratoconjunctivitis appear to be similar to those of atopic dermatitis. A
search for common food allergies, such as eggs, peanuts, milk, soy, wheat, or fish is important.
Airborne allergens, particularly dust mites and pet dander, have been overlooked as a significant
contributing factor and should be evaluated and controlled.
The hallmark of treatment for allergic conjunctivitis is the use of potent antihistamines (similar to
those used in atopic dermatitis) to subdue the itching. Topical antihistamines, mast-cell stabilizers,
and the short-term use of oral steroids are all beneficial for relief of the itching. Occasionally, an
infection of the area (usually with staphylococcus, commonly referred to as "staph") worsens the
symptoms, and antibiotic treatment may help control the itching. Allergy shots are useful in selected
cases.
Allergy alert
Atopic keratoconjunctivitis can lead to cataract formation in up to 10% of cases. In rare cases,
blindness can occur.
Vernal keratoconjunctivitis
Vernal keratoconjunctivitis is an uncommon condition that tends to occur in preadolescent boys (3:1
male to female ratio) and is usually outgrown during the late teens or early adulthood. (Vernal is
another term for "spring.") Vernal keratoconjunctivitis usually appears in the late spring and
particularly occurs in rural areas where dry, dusty, windy, and warm conditions prevail. The eyes
become intensely itchy, sensitive to light, and the lids feel uncomfortable and droopy. The eyes
produce a "stringy" discharge and, when examined, the surface under the upper eyelids appears
"cobblestoned." A closer examination of the eye reveals severe inflammation due to the vast number
of mast cells and accumulated eosinophils (a type of white blood cell involved in the allergic
response), producing so-called called "Trantas dots."
Improper treatment of vernal keratoconjunctivitis can lead to permanent visual impairment. The most
effective treatment appears to be a short-term course of low-dose topical steroids. Topical mast-cell
stabilizers and topical antihistamines can also be beneficial. Wraparound sunglasses are helpful to
protect the eyes against wind and dust.
Allergic conjunctivitis is a broad group of allergic conditions involving inflammation of the
conjunctiva. The commoner conditions are mild and do not affect the cornea. The rarer diseases
involve the cornea and can be sight-threatening.
Classification
1. Seasonal, intermittent, IgE-mediated allergic conjunctivitis (SAC)
2. Perennial, persistent, IgE-mediated allergic conjunctivitis (PAC)
These common IgE mediated diseases are related to seasonal or perennial allergens. They are
characterized by symptoms of ocular itching, watering and redness, and signs of hyperaemia and
oedema of the tarsal conjunctival surfaces. There is frequently an association with allergic rhinitis.
SAC is intermittent in nature, and, in temperate regions, follows exposure to pollen allergens in
sensitized individuals. PAC is a mild, persistent form of allergic conjunctivitis resulting from
continuing exposure to persistent allergens such as house dust mites.
Vernal keratoconjunctivitis (VKC)
This is a severe inflammatory disease which may be intermittent or, less frequently, persistent. VKC
is, in about 60% of cases, associated with IgE-dependent hypersensitivity. The symptoms are ocular
watering, stickiness, itching, and difficulty with opening the eyes on awaking. If the cornea is
involved, pain, blurred vision and photophobia are experienced. The signs are giant papillary
hyperplasia of the upper tarsal conjunctival surfaces, erosion of the corneal epithelium and
inflammation at the limbus (click for photograph).
Atopic keratoconjunctivitis (AKC)
This is a severe disease which is associated with atopic eczema. The condition is lifelong, starting in
the third of fourth decade. IgE-mediated mechanisms may be implicated. The symptoms are
perpetual ocular itching, soreness, impaired vision and a sensation of dryness (click for photograph).
Signs include chronic lid margin infection, chronic cicatrising conjunctivitis, eczema of the eyelids,
tear abnormality, and progressive scarring and vascularization of the cornea.
Giant papillary conjunctivitis (GPC)
This disease, also known as foreign body associated papillary conjunctivitis, results from trauma
caused by contact lens edges, ocular protheses or post-operative sutures. It may also evolve from
spontaneous lid eversion resulting in conjunctival rubbing against the pillow, the so-called floppy
eyelid syndrome. Upper subtarsal papillae, not always giant in size (> 1mm), is the hallmark sign of
the disease. There is no evidence that generally IgE-sensitized individuals are at greater risk of
developing the disease. The cornea is rarely involved.
Causes
Seasonal, intermittent, IgE-mediated allergic conjunctivitis
Seasonal, intermittent, allergic conjunctivitis is triggered by the same allergens responsible for
intermittent allergic rhinitis. In the Northern Hemisphere these are tree pollens in April/May, grass
pollens in June/July, and mold spores and weed pollens in July/August.
Perennial, persistent, IgE-mediated allergic conjunctivitis
Perennial, persistent, allergic conjunctivitis is triggered by house dust mites, molds and animal
allergens, which may be present year round, although the symptoms do show some seasonal
variation. In the Southern Hemisphere the pollen season can be all year round, depending on the
region.
Vernal keratoconjunctivitis
The majority of cases of VKC are intermittent and can occur during the high pollen season, although
persistent cases do occur in warm subtropical or desert climates. Published reports of the association
with IgE-mediated atopic disease vary between 15% to 60%. While there is a relationship between
the condition and positive skin tests, the relationship is not necessarily causal.
Atopic keratoconjunctivitis
AKC is a perennial disease which, when associated with the IgE-mediated subgroup of atopic
eczema, may be exacerbated by contact with specific allergens such as house dust mites, mold
spores, animal danders and rarely foods.
Giant papillary conjunctivitis
Giant Papillary Conjunctivitis occurs in the presence of foreign bodies in the eye, such as contact
lenses or ocular prostheses. Papillae develop on the upper tarsal conjunctiva along the line of contact
with the source of mechanical trauma, e.g., the lens edge. The upper eyelid may be traumatized with
each blink of the eye, which occurs between 10,000 and 12,000 times daily, and the area of trauma
may serve as an entrance for antigen possibly derived from altered proteins or chemicals in contact
lens solutions, although no single causative allergen has been identified in this condition to date.
Diagnosis of Allergic Conjunctivitis
Clinical examination and investigations
Appearance of the everted eyelid. This may be performed by using a long thin object, such as a
cotton bud, as a fulcrum at the top of the tarsal plate, while the eyelashes are pulled forward and up.

Conjunctival scrapings for eosinophils may be helpful

Skin prick/puncture tests or specific IgE tests to identify causative allergens

Clinical history
Typical symptoms

80% of patients are under 30 years of age

Strong personal or family history of IgE-mediated diseases

Recurrent intermittent or persistent symptoms

Mediators of IgE-related reactions in allergic conjunctivitis

Histamine: Itching, redness, oedema

Prostaglandins: Sensitized nerves, enhanced pain, oedema and redness

Leukotrienes: Chemotaxis, oedema and vascular permeability

Chemotactic factors: Recruitment of eosinophils and neutrophils leading to tissue destruction
Differential diagnoses of allergic conjunctivitis include

Atopic blepharitis

Bacterial conjunctivitis

Chlamydial conjunctivitis

Corneal abrasion or ulceration

Dry eye

Episcleritis

Epithelial microcysts and vacuoles

Staphylococcal marginal keratitis

Superficial punctate keratitis

Tight lens syndrome

Viral conjunctivitis or keratitis
Ocular itching is a cardinal symptom of allergic eye disease and in the absence of itching an
alternative diagnosis should be suspected.
Epidemiology
SAC
SAC may occur alone or as a component of seasonal/intermittent allergic rhinitis (hay fever). Both
SAC and PAC are primarily diseases of young adults, and there is a slightly higher prevalence in
males.
VKC
VKC is a disease of childhood and early adolescence. Genetic factors and atopic status may be
involved in the development of the disease, although many patients have no familial or personal
history of atopy, and may have negative allergy diagnostic tests. Thus, like atopic eczema it might
represent a syndrome with allergic and non-allergic subgroups. Males are more frequently affected
than females, with a ratio of 3:1. The disease usually begins before the age of 10 years and remits at
the time of puberty, although the age of affected individuals ranges from 3 to 25 years of age. VKC
may progress to atopic keratoconjunctivitis.
VKC occurs more frequently in warm climates and subtropical areas, in particular the Mediterranean
area, central Africa, India and South America. It is also reported in Australia, China, Japan and North
America. The incidence of the disease in cooler climates in Northern Europe is thought to reflect
migration of susceptible individuals, and it is thought that both genetic and environmental factors
contribute to the development of the disease.
AKC
AKC first occurs in the late teens or early twenties with a peak incidence between the ages of 30 – 50
years. It is more frequent in men and occurs in up to 25% of patients with atopic eczema. There is
usually a personal or family history of atopic disease.
GPC
GPC associated with contact lens use reflects the age of contact lens wearers and thus rarely occurs in
children or the elderly. However when associated with post-surgical mechanical trauma, such as
exposed sutures, it is more prevalent in older age groups. There is no gender predominance.
Prevention
Allergen avoidance can lead to significant improvement in symptoms of SAC and PAC. In GPC, the
use of disposable contact lenses may be helpful if lens deposits are causing symptoms, and changing
to daily use of disposable lenses can eliminate the condition entirely.
Treatment
Recommendations for the treatment of seasonal, intermittent, and perennial, persistent allergic
conjunctivitis are available on the GLORIA area of this website. Treatment of the rarer, more severe
forms of allergic conjunctivitis requires the use of topical corticosteroids and should be managed by
an ophthalmologist. Prolonged use of topical steroids in the eye can lead to secondary bacterial
infection, intra-ocular hypertension, glaucoma and cataract, and thus regular monitoring is essential.
To print out WAO's pocket chart on treatment of allergic rhinitis and allergic conjunctivitis, click
here.
VKC
Cromones and other mast cell stabilisers may be prescribed alone, or in addition to topical steroid
therapy. Mucolytic drops (acetylcisteine 5% or 10%) may be used to control the symptoms caused by
abnormal mucus.
AKC
In addition to topical corticosteroid therapy, treatment of the infected lid margins with topical or
systemic antibiotic may help to reduce symptoms. Cromones and other mast cell stabilizers may be
of value. Treatment of eye lid eczema with steroid ointments may be of value.
GPC
The condition, fit and cleaning schedule of contact lenses or prosthesis should be reviewed. Opticrom
or similar drugs may be used if required. Topical steroids should not be used for contact lens wearers,
but may be given for prosthesis wearers, where no risk to damage of the eye can occur.
SUMMARY:
Recent findings continue to expand our basic knowledge of mechanisms and differences between
seasonal and perennial allergic conjunctivitis and atopic and vernal keratoconjunctivitis.
Understanding the complex interactions and cross talk between cells, cytokines and other mediators
is relevant for new therapeutic approaches directed at specific disease entities.