Allergic Eye Disease

Ocular allergy is one of the most common conditions encountered by pediatricians and ophthalmologists and is characterized by bilateral injection with itching as the predominant symptom. Risk factors include history of atopy (asthma, eczema, seasonal allergies). Basic and clinical research have provided insight into the immunologic mechanisms, clinical presentation, differential diagnosis, and pharmacologicmanagement of this condition. New pharmacologic agents have improved the efficacy and safety of ocularallergy treatment. This article discusses the classification of ocular allergy diagnosis and management, and addresses clinical symptoms and signs that indicate more severe allergic disease or alternative diagnosis that should prompt expeditious referral to an ophthalmologist.

Key points

  • •

    Allergic eye disease is almost always bilateral, and itching is the predominant symptom.

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    Allergic eye disease can be clinically and pathophysiologically classified as seasonal allergic conjunctivitis, perennial allergic conjunctivitis, vernal keratoconjunctivitis, atopic keratoconjunctivitis, contact blepharoconjunctivitis, and giant papillary conjunctivitis.

  • •

    The first step in management is avoidance of allergen and cessation of eye rubbing.

  • •

    For mild cases without evidence of corneal involvement, treatment with a combination of topical antihistamines mast cell stabilizers is highly effective, and topical nonsteroidal anti-inflammatory drugs and steroids should be prescribed by an ophthalmologist.

  • •

    The presence of pain, visual impairment, or evidence of corneal involvement should prompt referral to an ophthalmologist for further management.

Introduction

Ocular allergy, affecting approximately 10% to 20% of the US population, is one of the most common ocular disorders encountered by pediatricians and ophthalmologists. Patients with ocular allergy often present with bilateral inflammation of the eyelid and conjunctiva that may be associated with rhinitis, asthma, or other atopic conditions. Allergic eye disease is classified into seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), contact blepharoconjunctivitis, and giant papillary conjunctivitis ( Table 1 ). The predominant symptom is itching and redness, and mucinous discharge or photophobia may be present. If pain is present, vision is impaired, the cornea is involved, or symptoms do not improve with treatment, the clinician should refer the patient to an ophthalmologist. A basic understanding of eye surface anatomy is required to fully appreciate key diagnostic elements. Initial treatment involves a combination of topical antihistamines and mast cell stabilizers. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and occasionally short-term use of topical steroids should be prescribed ideally by an ophthalmologist, because both medications can have complications that are difficult to recognize without a detailed ophthalmic examination.

Table 1
Clinical presentation and characteristics of ocular allergy
Characteristic SAC PAC VKC AKC CBC GPC
Age All ages All ages <20 y (male>female) Adulthood (male>female) All ages All ages
Onset Childhood Childhood Preadolescence Any age Any age Any age
Allergens Tree pollens (early spring) Weed pollen (August–October) Outdoor molds Grasses (May–July) Dust mites Animal dander Mold Air pollutants Seasonal allergens Any can contribute Cosmetics Ophthalmic eye drops Inert chemicals Foreign body Contact lenses Suture material Prosthesis
Seasonal Yes No Yes No No No
Personal or family history of atopy Common Common Possible Always Possible Possible
Contact lens wear No No No No Possible Yes
Symptoms Itching Tearing Photophobia Itching Tearing Photophobia Itching Copious mucous Photophobia Itching Burning Photophobia Itching Burning Photophobia Itching Tearing Photophobia
Pathophysiology IgE-mediated Type I hypersensitivity IgE-mediated Type I hypersensitivity IgE-mediated Type I and IV hypersensitivity IgE-mediated Type I and IV hypersensitivity Type IV hypersensitivity IgE-mediated Type I and IV hypersensitivity
Conjunctival eosinophilia Yes Yes Always Always (acute phase) Occasional Rare
Serum IgE Mildly elevated Mildly elevated Elevated Elevated Variable Variable
Goblet cells Elevated Elevated Marked elevation Decreased Variable Variable
Periocular skin involvement Sometimes edema Sometimes edema Sometimes edema Sometimes edema, sometimes eczema Dermatitis, sometimes edema Sometimes edema
Visual impairment +/− +/− ++ +++ +/− +/−
Conjunctival reaction Papillary Papillary Giant papillary reaction (upper tarsus) Papillary reaction/thickened (upper tarsus) Papillary or follicular response Giant papillary reaction
Corneal involvement +/− +/− ++ ++++ + +
Skin tests Positive Positive Positive Positive Variable Variable
Natural history Self-limited; symptomatic treatment Self-limited; symptomatic treatment Requires treatment; usually resolves by age 20 y Chronic Short-term; requires treatment Chronic; contact lens associated
Concurrent ocular complications None None Shield ulcer (sterile ulcer) Cataracts Secondary infections (HSV, staphylococcal) Glaucoma None Peripheral corneal pannus
First-line prophylaxis Avoidance Mast cell stabilizers Avoidance Mast cell stabilizers Mast cell stabilizers Avoidance Mast cell stabilizers Avoidance Avoidance Mast cell stabilizers
First-line acute treatment Topical antihistamine/mast cell stabilizers Topical antihistamine/mast cell stabilizers Should be treated by ophthalmologist Topical antihistamine/mast cell stabilizers Topical cyclosporine Topical mild steroid Allergist referral Possible systemic treatment Topical corticosteroid pulse Should be treated by ophthalmologist Topical antihistamine/mast cell stabilizers Topical cyclosporine Topical mild steroid Allergist referral Possible systemic treatment May require chronic treatment Topical corticosteroid pulse Mild topical corticosteroid to periocular skin Topical antihistamine/mast cell stabilizers
Abbreviations: CBC, contact blepharoconjunctivitis; GPC, giant papillary conjunctivitis; HSV, herpes simplex virus; PAC, perenneal allergic conjunctivitis; SAC, seasonal allergic conjunctivitis; VKC, vernal keratoconjunctivits; +/−, may or may not be present; +, sometimes present; ++, usually present; +++, often present; ++++, always present.

Introduction

Ocular allergy, affecting approximately 10% to 20% of the US population, is one of the most common ocular disorders encountered by pediatricians and ophthalmologists. Patients with ocular allergy often present with bilateral inflammation of the eyelid and conjunctiva that may be associated with rhinitis, asthma, or other atopic conditions. Allergic eye disease is classified into seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), contact blepharoconjunctivitis, and giant papillary conjunctivitis ( Table 1 ). The predominant symptom is itching and redness, and mucinous discharge or photophobia may be present. If pain is present, vision is impaired, the cornea is involved, or symptoms do not improve with treatment, the clinician should refer the patient to an ophthalmologist. A basic understanding of eye surface anatomy is required to fully appreciate key diagnostic elements. Initial treatment involves a combination of topical antihistamines and mast cell stabilizers. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and occasionally short-term use of topical steroids should be prescribed ideally by an ophthalmologist, because both medications can have complications that are difficult to recognize without a detailed ophthalmic examination.

Table 1
Clinical presentation and characteristics of ocular allergy
Characteristic SAC PAC VKC AKC CBC GPC
Age All ages All ages <20 y (male>female) Adulthood (male>female) All ages All ages
Onset Childhood Childhood Preadolescence Any age Any age Any age
Allergens Tree pollens (early spring) Weed pollen (August–October) Outdoor molds Grasses (May–July) Dust mites Animal dander Mold Air pollutants Seasonal allergens Any can contribute Cosmetics Ophthalmic eye drops Inert chemicals Foreign body Contact lenses Suture material Prosthesis
Seasonal Yes No Yes No No No
Personal or family history of atopy Common Common Possible Always Possible Possible
Contact lens wear No No No No Possible Yes
Symptoms Itching Tearing Photophobia Itching Tearing Photophobia Itching Copious mucous Photophobia Itching Burning Photophobia Itching Burning Photophobia Itching Tearing Photophobia
Pathophysiology IgE-mediated Type I hypersensitivity IgE-mediated Type I hypersensitivity IgE-mediated Type I and IV hypersensitivity IgE-mediated Type I and IV hypersensitivity Type IV hypersensitivity IgE-mediated Type I and IV hypersensitivity
Conjunctival eosinophilia Yes Yes Always Always (acute phase) Occasional Rare
Serum IgE Mildly elevated Mildly elevated Elevated Elevated Variable Variable
Goblet cells Elevated Elevated Marked elevation Decreased Variable Variable
Periocular skin involvement Sometimes edema Sometimes edema Sometimes edema Sometimes edema, sometimes eczema Dermatitis, sometimes edema Sometimes edema
Visual impairment +/− +/− ++ +++ +/− +/−
Conjunctival reaction Papillary Papillary Giant papillary reaction (upper tarsus) Papillary reaction/thickened (upper tarsus) Papillary or follicular response Giant papillary reaction
Corneal involvement +/− +/− ++ ++++ + +
Skin tests Positive Positive Positive Positive Variable Variable
Natural history Self-limited; symptomatic treatment Self-limited; symptomatic treatment Requires treatment; usually resolves by age 20 y Chronic Short-term; requires treatment Chronic; contact lens associated
Concurrent ocular complications None None Shield ulcer (sterile ulcer) Cataracts Secondary infections (HSV, staphylococcal) Glaucoma None Peripheral corneal pannus
First-line prophylaxis Avoidance Mast cell stabilizers Avoidance Mast cell stabilizers Mast cell stabilizers Avoidance Mast cell stabilizers Avoidance Avoidance Mast cell stabilizers
First-line acute treatment Topical antihistamine/mast cell stabilizers Topical antihistamine/mast cell stabilizers Should be treated by ophthalmologist Topical antihistamine/mast cell stabilizers Topical cyclosporine Topical mild steroid Allergist referral Possible systemic treatment Topical corticosteroid pulse Should be treated by ophthalmologist Topical antihistamine/mast cell stabilizers Topical cyclosporine Topical mild steroid Allergist referral Possible systemic treatment May require chronic treatment Topical corticosteroid pulse Mild topical corticosteroid to periocular skin Topical antihistamine/mast cell stabilizers

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Oct 2, 2017 | Posted by in PEDIATRICS | Comments Off on Allergic Eye Disease

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