Allergic conjunctivitis

1. Seminar of ophthalmology Topic: allergic conjunctivitis Presented by: Swornim Gyawali Roll no :25 MBBS 2010 batch Gandaki medical college

2. Allergic conjunctivitis : Types: Simple allergic conjunctivitis hay fever conjunctivitis seasonal allergic conjunctivitis (SAC) perennial allergic conjunctivitis(PAC) 2. Vernal keratoconjunctivitis (VKC) 3. Atopic keratoconjunctivitis (AKC) 4. Giant papillary conjunctivitis (GPC) 5. Phlyctenular keratoconjunctivitis (PKC) 6. Contact dermoconjunctivitis (CDC)

3. Simple Allergic Conjunctivitis Mild ,non specific IgE mediated Type I hypersensitivity reaction Etiology : Hay fever conjunctivitis : associated with allergic rhinitis Allergens : pollens , grass , animal dandruffs SAC: common , d/t: grass pollens PAC: not common , d/t: house dust and mites

4. SAC Pathology: Vascular response : vasodilation increased vessel permeability exudation Cellular response : Conjunctival infiltration (eosinophil , plasma cells and mast cells ) and exudation producing histamine and histamine like substance Conjunctival response : boggy swelling , increase connective tissue formation and mild papillary hyperplasia

5. Symptoms: itching burning sensation in the eye watery discharge and mild photophobia Signs : hyperemia and chemosis mild papillary reaction oedema of eyelids SAC

6. Management : Exposure to allergens should be reduced as far as possible Cold compresses Topical tear substitutes to flush out allergens medications: vasoconstrictors Mast cell stabilizer: sodium chromoglycate 2% [ QID] severe and non-responsive: steroids Systemic antihistamines : Cetirizine 10 mg OD( acute with marked itching)

7. Vernal keratoconjunctivitis Recurrent , bilateral , interstitial ,self limiting, Age : 4- 20 yrs , sex: boys > girls Season: Summer hence the name SPRING CATARRH Etiology : IgE mediated hypersensitivity reaction Personal family history of hay fever, eczema , asthma Peripheral blood shows : eosinophilia increased IgE

8. VKC Pathology: Conjunctival epithelium : hyperplasia and downward projections into the sub epithelial tissue Adenoid layer : cellular infiltration by eosinophil's , plasma cells , lymphocytes and histiocytes . Fibrous layer : proliferation which later undergoes hyaline changes Conjunctival vessels : proliferation , increased permeability and vasodilation ALL THESE LEADS TO MULTIPLE PAPILLA FORMATION IN UPPER TARSAL CONJUNCTIVA

9. VKC symptoms Intense itching & burning sensation Lacrimation Foreign body sensation Photophobia, Thick mucous discharge [ ropy] 3 clinical form palpebral bulbar mixed form

10. Palpebral form Diffuse papillary hypertrophy, > on superior tarsus Papillae have a flat-topped polygonal appearance resembling COBBLESTONES Severe cases- Giant papillae, which may be coated with mucus

11. Limbal / Bulbar form May start as a thickening & opacification of limbus Limbal nodules - Mucoid nodules, which are gelatinous, elevated Horner- Trantas dots – composed mainly of eosinophils and epithelial debris ( limbal apices)

12. Vernal Keratopathy / Corneal involvement Punctate epithelial erosions to macroerosions Shield ulcers – Oval ulceration with thickened, opaque edges

13. Plaque formation – Occur when ulcer base becomes coated with desiccated mucus Results in – Subepithelial ring scarring Pseudogerontoxon – Arc like whitish peripheral corneal deposition ‘cupid’s bow’ outline in a inflamed segment of the limbus Clinical course : self limiting burns out spontaneously after 5 – 10 yrs

14. Treatment Local: Topical steroid : Every 4 hrs. for 2 days followed by 3-4 times a day for 2 weeks . MONITOR IOP TO PREVENT STEROID INDUCED GLAUCOMA Mast cell stabilizers : sodium chromoglycate 2 % drops 4-5 times/day Topical antihistamine Acetyl cysteine (0.5%) Topical cyclosporine (1%): severe unresponsive case

15. Systemic : Oral antihistamine : for itching Oral steroid : short course for very severe non responsive case Treatment of large papilla supratarsal injection of long acting steroid or cryo application or surgical removal General measures : dark goggles , cold compress , change of place from hot to cold

16. Atopic keratoconjunctivitis Adult equivalent of VKC Young atopic adults with male predominance May be associated with atopic dermatitis Symptoms ; itching , soreness , dry sensation , mucoid discharge , phtophobia or blurred vision Signs : lid margins: inflamed with round posterior borders tarsal : milky appearance , very fine papilla , hyperaemia scarring with shrinkage cornea- punctate epithelial keratitis in lower half, vascularization , plaque

17. Treatment : treat facial eczema and lid margin disease sodium chromoglycate steroids and tear drops

18. Giant papillary conjunctivitis Conjunctivitis with very large sized papilla Cause : allergic response to rough or deposited surface (contact lens , prosthesis, left out nylon suture ) Symptoms: itching , STRINGY DISCHARGE, reduced wearing time of contact lens or prosthetic shell Signs : papillary hypertrophy(1mm in diameter) of upper tarsus Treatment : Removal of cause disodium chromoglycate Steroids not much use

19. Phlyctenular conjunctivitis Characteristic nodular affection (an allergic response) Conjunctival and corneal epithelium to some endogenous allergens to which they have become sensitized. Etiology: Delayed type hypersensitivity in response to endogenous microbial protein. Previously tuberculus protein ,now staphylococcus other allergens : Moraxella axenfield and certain parasites. Predisposing factors: age – ( 3 to 15 yrs. ) , sex : F>M , undernourished

20. Pathology: 1. Stage of nodule formation: Conjunctival infiltration and exudation peripherally lymphocyte and central PMN cells nodule formation ( phylcten ) necrosis of apex of nodule 2. Stage of ulceration: ulceration 3.Satge of granulation: floor of ulcer covered with granulation tissue 4 .Stage of healing : healing with minimal scar formation

21. Symptoms : Discomfort in eye MUCOPURULENT conjunctivitis d/t secondary infection Reflex watering Sign: 3 forms Simple Phlyctenular conjunctivitis : pinkish white nodule surrounded by hyperaemia on bulbar conjunctiva Necrotizing Phlyctenular conjunctivitis: large phlycten with necrosis & ulceration leading to severe pustular conjunctivitis . Miliary Phlyctenular conjunctivitis: multiple phlycten arranged haphazardly or ring form

22. Phlyctenular keratitis Secondary extension of Conjunctival phlycten to cornea. Two forms : Ulcerative : Sacrofulous : shallow marginal ulcer(phlycten break down), no space between limbus and ulcer heals without leaving opacity. Fasicular : superficial, leaves parallel bundles of BV, band shaped superficial opacity Miliary : multiple ulceration scattered over Diffuse infiltrative : central infiltration of cornea with rich peripheral vascularization around limbus

23. Management of Phlyctenular conjunctivitis Local Topical steroid Antibiotic drops Atropine 1% eye ointment Specific Tuberculous infection ruled out Septic focus treated Parasitic infestation eradicated C. General Protein rich diet, vitamin A and vitamin D

24. Contact dermoconjunctivitis Allergic d/o, involvement of conjunctiva & skin lid along with some facial area Etiology: delayed type hyper sensitivity response to prolong contact with chemicals and ophthalmic medicines( atropine, neomycin, soframycin) C/F: Cutaneous involvement : weeping eczema around the area involved with medication Conjunctival response : lower fornix and lower palpebral conjunctiva Treatment: hyperaemia , papillary response Discontinuing of causative chemical or medications Topical steroid eye drops Steroid ointment in involved surrounding area

25. Clinical investigations: Skin prick test / positive result Different cell types infiltrate the conjunctiva SAC, PAC T cells Eosinophils Mast Cells Neutrophils GPC , VKC, AKC Mast cells Eosinophils Neutrophils

26. Effect of treatment :

27. Thank you for the patience!!!