allergic conjunctivitis my presentation 2.pptx

Atopy is a genetically determined predisposition to hypersensitivity reactions upon
exposure to specific environmental antigens.
•Clinical manifestations include the various forms of allergic conjunctivitis, as well
as hay fever (seasonal allergic rhinitis), asthma and eczema.
•Allergic conjunctivitis is a Type I (immediate) hypersensitivity reaction, mediated
by degranulation of mast cells in response to the action of IgE; there is evidence of
an element of Type IV hypersensitivity in at least some forms.

1. MANAGEMENT OF ALLERGIC CONJUNCTIVITIS DR AISHA AHMAD BARWA DEPARTMENT OF O PTHALMOLOGY ATBUTH BAUCHI WEDNESDAY 19 TH MARCH 2025

2. CONTENTS Introduction Classification Epidemiology Etiology Clinical picture Treatment refrences

3. INTRODUCTION Atopy is a genetically determined predisposition to hypersensitivity reactions upon exposure to specific environmental antigens. Clinical manifestations include the various forms of allergic conjunctivitis, as well as hay fever (seasonal allergic rhinitis), asthma and eczema. Allergic conjunctivitis is a Type I (immediate) hypersensitivity reaction, mediated by degranulation of mast cells in response to the action of IgE; there is evidence of an element of Type IV hypersensitivity in at least some forms.

4. CLASSIFICATION OF ALLERGIC CONJUNCTIVITIS Acute allergic conjunctivitis Seasonal allergic conjunctivitis (SAC) Perennial allergic conjunctivitis (PAC)  Vernal keratoconjunctivitis (VKC)  Atopic keratoconjunctivitis (AKC) Giant papillary conjunctivitis (GPC)

5. EPIDEMIOLOGY Allergic conjunctivitis is one of the most common forms of conjunctivitis. In a report from the National Health and Nutrition Examination Survey studying the epidemiology of allergic conjunctivitis, 6.4% and 29.7% of 20,010 patients reported ocular symptoms and combined ocular and nasal symptoms, respectively. 40% of the population reported experiencing at least 1 occurrence of ocular symptoms in the past 12 months.

6. ACUTE ALLERGIC CONJUNCTIVITIS Acute allergic conjunctivitis is a common condition caused by an acute conjunctival reaction to an environmental allergen, usually pollen. It is typically seen in younger children after playing outside in spring or summer. Acute itching and watering are common, but the hallmark is chemosis, which is frequently dramatic and worrying to the child and parents. Treatment is not usually required and the conjunctival swelling settles within hours as the acute increase in vascular permeability resolves. Cool compresses can be used and a single drop of adrenaline 0.1% may reduce extreme chemosis.

7. SEASONAL AND PERENNIAL ALLERGIC CONJUNCTIVITIS These common subacute conditions are distinguished from each other by the timing of exacerbations, thought to relate principally to differing stimulating allergens in each.

8. ETIOLOGY Seasonal allergic conjunctivitis (‘hay fever eyes’), worse during the spring and summer, is the most common. The most frequent allergens are tree and grass pollens, although the specific allergen varies with geographic location. Perennial allergic conjunctivitis causes symptoms throughout the year, generally worse in the autumn when exposure to house dust mites, animal dander and fungal allergens is greatest. It is less common and tends to be milder than the seasonal form.

9. CLINICAL PICTURE SYMPTOMS Transient acute or subacute attacks of redness watering Itching with associated sneezing and nasal discharge. SIGNS Hyperemia and chemosis which gives a swollen juicy appearance to conjunctiva Conjunctiva may also show mild papillary reaction edema of lids

10. TREATMENT Elimination of allergens if possible Artificial tears for mild symptoms. Mast cell stabilizers must be used for a few days before exerting maximal effect but are suitable for long-term use if required. Antihistamines can be used for symptomatic exacerbations and are as effective as mast cell stabilizers. Dual action antihistamine and mast cell stabilizers act rapidly and are often very effective for exacerbations. Combined preparation of an antihistamine and a vasoconstrictor Non-steroidal anti-inflammatory preparations can provide symptomatic relief but are rarely used. Topical steroids are effective but rarely necessary. Oral antihistamines may be indicated for severe symptoms.

11. VERNAL KERATOCONJUNCTIVITIS (VKC) Chronic Bilateral Recurrent Usually affects the tarsal and bulbar conjunctiva

12. ETIOLOGY It is considered a hypersensitivity reaction to some exogenous allergens, such as grass pollens B oth IgE- and cell-mediated immune mechanisms play important roles It primarily affects boys onset is generally from about the age of 5-20 years. There is remission by the late teens in 95% of cases, although many of the remainder develop atopic keratoconjunctivitis. VKC is rare in temperate regions but relatively common in warm dry climates such as the Mediterranean, sub-Saharan Africa and the Middle East. In temperate regions over 90% of patients have other atopic conditions such as asthma and eczema and two-thirds have a family history of atopy. VKC often occurs on a seasonal basis, with a peak incidence over late spring and summer, although there may be mild perennial symptoms.

13. CLASSIFICATION Palpebral VKC primarily involves the upper tarsal conjunctiva. It may be associated with significant corneal disease as a result of the close apposition between the inflamed conjunctiva and the corneal epithelium. Limbal disease typically affects black and Asian patients. Mixed VKC has features of both palpebral and limbal disease.

14. CLINICAL PICTURE SYMPTOMS VKC is characterised by marked burning and itching sensation which is usually intolerable and accentuated when patient comes in a warm humid atmosphere. Itching is more marked with palpebral form of disease. mild photophobia Lacrimation Foreign body sensation Thick mucoid discharge Increased blinking is common

15. SIGNS Signs of vernal keratoconjunctivitis can be described in following forms: Palpebral form. Usually upper tarsal conjunctiva of both eyes is involved. The typical lesion is characterized by the presence of hard, flat topped, papillae arranged in a 'cobble-stone' or 'pavement stone', fashion. In severe cases, papillae may hypertrophy to produce cauliflower like excrescences of 'giant papillae'. Conjunctival changes are associated with white mucoid discharge. Limbal form (Bulbar form). It is characterised by: (i) dusky red triangular congestion of bulbar conjunctiva in palpebral area; (ii) gelatinous thickened accumulation of tissue around the limbus; and (iii) presence of discrete whitish raised dots along the limbus (Horner- Trantas spots)  Mixed form. It shows combined features of both palpebral and limbal forms 

16. Palpebral form of VKC Limbal form of VKC

17. GRADING

18. CLINICAL COURSE AND DIFFERENTIAL DIAGNOSIS CLINICAL COURSE disease is often self-limiting and usually burns out spontaneously after 5-10 years. DIFFERENTIAL DIAGNOSIS Palpebral form of VKC needs to be differentiated from trachoma with pre-dominant papillary hypertrophy 

19. ATOPIC KERATOCONJUNCTIVITIS (AKC) Adult equivalent of VKC Associated with atopic dermatitis Most of the patients are young Atopic adults

20. ETIOLOGY Is a rare bilateral disease that typically develops in adulthood (peak incidence 30–50 years) following a long history of atopic dermatitis (eczema); asthma is also extremely common in these patients. About 5% have suffered from childhood VKC. There is little or no gender preponderance. AKC tends to be chronic and unremitting, with a relatively low expectation of eventual resolution, and is associated with significant visual morbidity. AKC tends to be perennial and is often worse in the winter, Whereas VKC is more frequently seasonal and generally worse in the spring, Patients are sensitive to a wide range of airborne environmental allergens.

21. CLINICAL PICTURE The distinction between AKC and VKC is essentially clinical. Symptoms are similar to those of VKC, but are frequently more severe and unremitting . Symptoms include: Itching. Soreness Dry sensation Blurred vision Mucoid discharge. Photophobia.

22. Signs Lid margins are chronically inflamed with rounded posterior borders. Tarsal conjunctiva has a milky appearance. There are very fine papillae, hyperaemia and scarring with shrinkage. Cornea may show punctate epithelial keratitis, often more severe in lower half. There may also occur corneal vascularization, thinning and plaques.

23. CLINICAL COURSE Clinical course. AKC has a protracted course with exacerbations and remissions. tends to become inactive when the patient reaches the fifth decade. Associations may be keratoconus and atopic cataract.

24. TREATMENT OF VKC AND AKC General measures Allergen avoidance Dark goggles to prevent photophobia. Cold compresses and ice packs have soothing effects. Local treatment Mast cell stabilizers reduce the frequency of acute exacerbations and the need for steroids and so form the basis of many regimens but are seldom effective in isolation. Several days to weeks of treatment are needed for a reasonable response and long-term therapy may be needed . Topical antihistamines when used in isolation are about as effective as mast cell stabilizers. They are suitable for acute exacerbations but generally not for continuous long-term use. Combined antihistamine and vasoconstrictor may offer relief in some cases. Combined action antihistamine/mast cell stabilizers are helpful in many patients and have a relatively rapid onset of action.

25. TREATMENT OF VKC AND AKC Non-steroidal anti-inflammatory preparations may improve comfort by blocking non-histamine mediators. Combining one of these with a mast cell stabilizer is an effective regimen in some patients. Topical steroids are used for (a) severe exacerbations of conjunctivitis and (b) significant keratopathy; reducing conjunctival activity generally leads to corneal improvement. They are usually prescribed in short but intensive (e.g. 2-hourly initially) courses, aiming for very prompt tapering. Although the risk of elevation of intraocular pressure is low, monitoring is advisable if long-term treatment is necessary. Steroid ointment may be used to treat the eyelids in AKC, though as with eye drops, the duration of treatment should be minimized and the intraocular pressure (IOP) monitored. Antibiotics may be used in conjunction with steroids in severe keratopathy to prevent or treat bacterial infection. Acetylcysteine is a mucolytic agent that is useful in VKC for dissolving mucus filaments and deposits and addressing early plaque formation .

26. TREATMENT OF VKC AND AKC Immune modulators have been recently reported to be effective in severe unresponsive cases Supratarsal steroid injection may be considered in severe palpebral disease or for non-compliant patients. Systemic treatment Oral antihistamines may provide some relief from itching in severe cases Antibiotics may be given to reduce blepharitis-aggravated inflammation, usually in AKC. Immunosuppressive agents (e.g. steroids, ciclosporin, tacrolimus, azathioprine) may be effective at relatively low doses in AKC unresponsive to other measures. Short courses of high-dose steroids may be necessary to achieve rapid control in severe disease. .

27. GIANT PAPILLARY CONJUNCTIVITIS (GPC) Mechanically induced papillary conjunctivitis, the severe form of which is known as giant papillary conjunctivitis (GPC), can occur secondary to a variety of mechanical stimuli of the tarsal conjunctiva .

28. ETIOLOGY It is most frequently encountered with contact lens (CL) wear, when it is termed contact lens-associated papillary conjunctivitis (CLPC). The risk is increased by the build-up of proteinaceous deposits and cellular debris on the contact lens surface. Ocular prostheses, exposed sutures and scleral buckles, corneal surface irregularity and filtering blebs can all be responsible. A related phenomenon is the so-called ‘mucus fishing syndrome’, when, in a variety of underlying anterior segment disorders, patients develop or exacerbate a chronic papillary reaction due to repetitive manual removal of mucus. Giant papillae can also be seen in other conditions such as VKC and AKC.

29. CLINICAL PICTURE Symptoms Itching Redness Foreign body sensation Increased mucus production reduced wearing time of contact lens or prosthetic shell.  Signs Papillary hypertrophy (>1.0 mm in diameter) of the upper tarsal conjunctiva, similar to that seen in palpebral form of VKC with hyperaemia are the main signs  

30. TREATMENT The offending cause should be removed. After discontinuation of contact lens or artificial eye or removal of nylon sutures, the papillae resolve over a period of one month. Ensure effective cleaning of CL or prosthesis Mast cell stabilizers should be non-preserved in patients wearing soft contact lenses, or can be instilled when the lenses are not in the eye, with a delay of perhaps half an hour after drop instillation prior to lens insertion. Most can be continued long-term if necessary. Antihistamines, non-steroidal anti-inflammatory agents and combined antihistamines/mast cell stabilizers may each be of benefit. Topical steroids can be used for the acute phase of resistant cases, particularly those where effective removal of the stimulus is difficult, as in bleb-related disease.

31. REFERENCES Clinical Ophthalmology: A Systemic Approach. 8th edition. J.J Kanski, Brad Bowling. E yewiki https://eyewiki.org/ Allergic_Conjunctivitis Comprehensive opthalmology. 4th edition.AK Khrana

32. THANK YOU