Ocular Manifestation and Treatment of Allergic Disorders
Greg Caldwell, OD, FAAO
225 Terrace Drive
Lilly, PA 15938
814-931-2030 mobile
Grubc@aol.com
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
Ocular allergies affect 20% of the population
A. 90% of all allergy patients have ocular symptoms
B. 50 million people suffer from ocular allergies
What is an Allergy?
A. Allergy-is a result of a beneficial immune response that has gone awry
B. Hypersensitivity-is a result of a beneficial immune response that has gone
awry
Normal Immune Response
When a specific immune response is not appropriately controlled, a phenomenon
termed hypersensitivity ensues.
Coombs and Gell Classification Hypersensitivity
A. Type I
Allergy
B. Type II
Cytotoxic, antibody-dependent
C. Type III
Immune Complex disease
D. Type IV
Delay Type Hypersensitivity
Why This Language Get So Confusing?
A. The same language is used to describe
B. Hypersensitivity-Type I, II, III and IV
C. Autoimmune disease-Type I, II, III and IV
D. Immune disorders=Hypersensitivity + Autoimmune diseases
Hypersensitivity
A. Type I-allergy, atopy, IgE
1. Only hypersensitivity-atopic dermatitis, allergic conjunctivitis
2. There are no autoimmune disease
B. Type II-antibody dependent cell mediated cytotoxicity IgM, IgG
1. Hypersensitivity-Pernicious anemia
2. Autoimmune-Rheumatic fever, Graves’, Myasthenia gravis
C. Type III-Immune Complex
1. Hypersensitivity-Reactive arthritis, rheumatoid arthritis
2. Autoimmune-Systemic lupus erythematosus
D. Type IV-cell mediated, T-cells
1. Hypersensitivity-contact dermatitis
2. Autoimmune-DM type 1, Hashimoto’s and GCA
True ocular allergy
A. Hypersensitivity Type I and IV
B. We may see ocular side effects from Type I thru IV hypersensitive and
autoimmune diseases but they are secondary and not true ocular allergy
Hypersensitivity
A. Type I
B. Allergy (immediate)
C. Atopy syndrome, anaphylaxis, asthma
D. Atopy-affecting parts of the body not in direct contact with the allergen.
Elevated levels of IgE in the blood…result positve skin prick test to common
allergens.
E. IgE
X.
XI.
XII.
XIII.
Hypersensitivity
A. Type I- IgE response to a particular antigen termed an allergen
1. Typically mediated by mast cells and particularly histamine
2. Ex. Allergic conjunctivitis
B. Type II- IgM or IgG response. Antibody binds to cell surface antigens on cells
or tissues
1. IE. Autoimmune hemolytic anemia, thrombocytopenia, pemphigus
C. Type III- Immune complex disease. Normally antibody antigen combine, an
immune complex is formed. These complexes usually are cleared from
systemic circulation by phagocytes. Poorly cleared immune complexes that
persist in circulation can lead to systemic disease.
1. IE. Systemic Lupus Erythematosis and Polyarteritis nodosa
D. Type IV- Delayed type hypersensitivity
1. Regulated by T-cells
2. Sub-categories:
a. Contact
b. Tuberculin
c. Granulomatous
Classification of Ocular Allergy
A. Allergic conjunctivitis
1. Seasonal
2. Perennial
B. Atopic keratoconjunctivitis
C. Vernal keratoconjunctivitis
D. Giant papillary conjunctivitis
E. Contact dermatitis
32 year old man
A. My eyes itch so bad I want to claw them out, I went golfing today (May),
Rubbing them feels good but I think it makes it worse, vision and externals are
normal
B. Seasonal Allergic Conjunctivitis
1. Occurs in spring, fall or both
2. Grass, tree pollen or ragweed
C. Perennial
1. Year round with periods that are more pronounced
2. Animal dander, dust mites, mold, grass
3. History of other atopic diseases
Signs and Symptoms of Allergic Conjunctivitis
A. Seasonal
B. Itching
C. Redness
D. Burning
E. Excessive tearing
F. Stringy white mucus
G. Rhinitis
XIV. Non-pharmacologic Interventions
A. Allergen avoidance
B. Pet control
C. Use air conditioning, HEPA filters
D. Avoid outdoor activities during high pollen periods
E. Cold compresses
F. Lubricating eye drops
G. Wash your hair before going to bed
XV.
Pharmacologic Interventions
A. Pataday
B. Alrex
C. Lotemax
XVI. What is happening and how do these pharmaceuticals work?
A. Ocular Allergy is Mainly Type I Hypersensitivity
B. Consists of three phases
1. Sensitization phase- patient unaware
2. Activation phase (early allergic response)
3. Late allergic response
XVII.
XVIII.
XIX.
XX.
Histamine Receptors
A. Three subtypes of the histamine receptor have been pharmacologically defined
(H1, H2, H3)
B. Selective stimulation of ocular H1 receptors results in ocular itching and
vasodilation
C. Selective stimulation of ocular H2 receptors produces vasodilation and redness
without itching
28 year old man, was helping set up tents and tables for a church event, eye became
itchy, he rubbed it and within one hour it became very swollen. The eye is still very
itchy and watery
A. Slit Lamp Exam
B. Diagnosis?
C. Treatment?
D. Is this a Type 1 or Type 4 Hypersensitivity Reaction?
6 year old boy, eyes are red and itchy again since the beginning of April, now May
10th, “He rubs them all the time”. He is already using Pataday 1 gtt qd OU, Rxed by
pediatrician, uses it everyday. Used to get mucous and discharge from the eye but
has not since on Pataday.
A. Let’s take a look
B. Vernal Conjunctivitis
1. Ages 3-25, peak incidence 11-13y/o, lasts 4-11 yrs
2. males>females
3. Thick ropy discharge, severe itching and corneal involvement, worse
spring and summer
4. Important clinical signs:
5. Large papillae, Horner-Trantas dots
6. SPK
7. Well demarcated sterile ulcer (shield ulcer)
8. Type I hypersensitivity
9. With early and late phases
10. Children generally will outgrow this allergy
11. Their super-immune system slows down
12. Take a shower and wash hair before going to bed
13. NP AT
14. Cont Pataday
15. Add Alrex qid
25 year old man, my eyes are red and itchy all year round. At times of the year they
are worse, like today. I do cold compresses, artificial tears and Pataday. This seems
to help but my eyes are really never white, clear and have some itch. “I thought
allergies occurred in the spring and summer”. I work with the public and my clients
always ask about my eyes. Patient has eczema and avoids many detergents and
perfumes. Patient also suffers from asthma and uses inhalers
A. Let’s take a look
B. Atopic Keratoconjunctivitis
C. Atopic keratoconjunctivitis (AKC) is the result of a condition called "Atopy"
D. Atopy is a genetic condition whereby the immune system produces higher
than normal antibodies in response to a given allergen
E. There is usually a family history of multiple allergies
F. Although AKC is a perennial disease, symptoms tend to worsen in the
winter (dryness)
G. Atopic dermatitis which is generally seen early in childhood
H. Atopic keratoconjunctivitis appears during late adolescence
1. Men are more commonly affected than women.
XXI.
XXII.
64 year old woman, diagnosed with bacterial conjunctivitis 8 days ago OD. Used
Tobramycin qid OD, appeared to be worsening, was told to use q2 hours.
A. In today for second opinion
B. Discussion
C. Type 4 Hypersensitivity
D. Delayed/ cell mediated
1. Occur in hours, days to months after antigen challenge
2. T cell mediated
3. Etiology: contact dermatitis, topical medications, jewelry, nail
polish
4. Manifestations:
5. Itching
6. Red lids
7. Superficial skin changes
E. Contact Dermatitis
1. Causes: Topical Medications, Alpha agonists, B-blocker,
Pilocarpine, Atropine, Contact lens solutions, Cosmetics, Fingernail
polish, Pet dander, Molds, Detergents, Latex, Hair dye, Metals:
nickel
73 year old man, in today because his “pink eye” that he contracted from his
granddaughter will not clear up, started 3 weeks ago, worsened for 2 weeks, now
stable
A. Discussion
B. Glaucoma patient using
1. ½ %Betimol qd OU AM
2. Alphagan-P 0.15% bid OU
3. Travatan Z qd OU PM
C. Is this a Type 1 or Type 4 Hypersensitivity Reaction?
XXIII.
Another 0.2% Brimonidine Hypersensitivity
A. Type 1 and Type 4 Ocular Allergy
XXIV.
37 year old woman. Previously treated for contact lens overwear with Maxitrol
(antibiotic and steroid) qid, told she had sterile ulcers. With Maxitrol (antibiotic and
steroid) eyes feel better in 2 days. Her eyes are red and irritated, 3rd time this year,
wants 2nd opinion and treatment. Wore contact lens for 3 weeks, average wearing
time 8-10 hrs, before this episode started
A. Slit lamp exam
B. Any thoughts?
C. Why so recurrent?
D. Treatment?
E. D/C CL wear , until resolved
F. Pataday
G. Tobradex-until cornea clear
H. Lotemax
I. Artificial tears
J. Once resolved-Maintenance dose of mast cell stabilizer
K. SCL –vs- RGP-vs- vision correction
XXV.
XXVI.
XXVII.
Giant Papillary Conjunctivitis
A. Condition characterized by formation of large papillae (>0.3mm) on the
superior palpebral conjunctiva
B. No seasonal variation
C. Etiology
1.Contact lens wear
2.Exposed sutures (conjunctiva or cornea)
3.Prosthesis
D. Pathophysiology
1.Mechanical trauma induces inflammatory cascade and mast cell
degranulation
2.No increase in histamine levels
3.Plasma cells, mast cells, eosinophils and basophils are found in
cytologic scrapings. (Type I & IV)
4.Over-reaction of body’s immune system
5.Arachidonic acid cycle main component
E. Treatment
1.Decreased CL wearing time
2.Change to disposable soft CL’s, Dailies SCL, RGP
3.Mast cell stabilizers (Pataday)
4.Topical steroids (short term)-Lotemax
14 year old boy
A. Diagnosis and Treatment?
B. Phlyctenulosis-Focal nodule of inflammatory tissue
C. Two forms
1.Conjunctival
2.Corneal
D. Focal nodule can migrate from conjunctiva to cornea
E. Etiology
1.Staphylococcus (most common)
2.Rosacea
3.Tuberculosis
F. Treatment
1.Rule out tuberculosis if suspicious
2.Chest X-ray and PPD
3.Combination antibiotic/steroid
Thank you