Allergic Conjuntivitis

Allergic conjunctivitis of eye

1. Allergic Conjuntivitis Dr Kawshik Nag Phase B Resident Chittagong Medical College

2. Allergic conjunctivitis is the inflammation of conjunctiva due to hypersensitivity reactions which may be immediate( humoral ) or delayed(cellular). The conjunctiva is ten times more sensitive than skin to allergens.

3. Types Acute allergic conjunctivitis Seasonal and Perennial allergic conjunctivitis Vernal keratoconjunctivitis .(VKC) Atopic keratoconjunctivitis .(AKC) Giant papillary conjunctivitis.(GPC) Phlyctenular keratoconjunctivitis .(PKC) Contact allergen blepharoconjunctivitis

4. Acute allergic conjunctivitis It 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.

5. Clinical features : 1. Chemosis 2. Acute itching 3.Watering Treatment: -Usually not required -Cold compression can be used.

6. Seasonal And Perennial Allergic Conjunctivitis These are common subacute conditions which are distinguished from each other by the timming of exacerabations

7. Seasonal allergic conjunctivitis : - It is more common - Worse during the spring and summer - Common allergens are grass and pollens Perenneal allergic conjunctivitis : - Causes symptoms through out the year - Generally worse in the autumm - Allergens are dust mites, animal dander, fungal allergen - Less common and milder.

8. Clinical features: - Acute or subacute attacks of redness - Chemosis - Itching and watering -Sneezing and nasal discharge

9. Treatment: - Artificial tear - Mast cell stabilizer - Antihistamines - Dual action of antihistamine and mast cell stabilizer - Topical steroid - Oral antihistamine

10. Vernal Keratoconjunctivitis Pathogenesis : It is a recurrent bilateral disorder in which both IgE and cell mediated immune mechanism play important role. Atopic background play an important predisposing factor. Boys are more affected than girls and the onset of age is 5 years onwards. Peak incidence is over late spring and summer.

11. Classification 3 Types 1. Palpebral VKC - Involves upper tarsal conjunctiva and may be associated with significant corneal disese 2. Limbal VKC 3.Mixed VKC

12. Diagnosis: ` Palpebral disease: Upper tarsal conjunctiva of both eye involved. Macropapillae arranged in a cobble-stone like appearance.

13. Macropapillae can progress into giant papillae. Mucus deposition between giant papillae. White ropy discharge may be present.

14. Limbal disease : Gelatinous limbal conjunctival papillae present. Horner- Trantas dots present

15. Vernal keratopathy : Superior punctate epithelial erosions with layer of mucus. Epithelial macroerosions caused by a combination of inflammatory mediators and a direct mechanical effect from papillae.

16. Vernal corneal plaques result from coating of macroerosion with a layer of exudates. Shield ulcer presents as a shallow transverse ulcer in upper part of cornea.

17. Pseudogerontoxon can develop in recurrent limbal disease. Subepithelial scars may present. Keratoconus and other ectasia disease is more common. Herpes simplex keratitis is more common here.

18. Atopic Keratoconjunctivitis It is a rare bilateral disease Typically develops in adulthood History of atopic dermatitis and asthma are common About 5% have suffered from childhood VKC.

19. Both IgE and cell mediated immune response play role. Associated with significant visual morbidity because it tends to be perennial and a wide range of airborne environmental allergen

20. Diagnosis Eyelids: Lid margins are chronically inflamed Chronic blepharitis and madarosis may present Keratinization of lid margin may be present.

21. Hertoghe sign : Absence of the lateral portion of the eyebrows. Dennie -Morgan folds : Lid skin folds caused by persistent rubbing

22. Conjunctiva: Normally involves inferior palpebral conjunctiva. Hyperaemia , chemosis and watery discharge present. Papillae are usually small. Diffuse conjunctival infiltration and scarring present

23. Cicatricial changes causes symblepharon formation and forniceal shortening. Keratinization of caruncle . Horner- trantas dots sometime present.

24. Keratopathy : Punctate epithelial erosions over inferior third of the cornea. Peripheral vascularization and stromal scarring present Persistant epithelial defect may progress to cornea perforation and descemetocele formation

25. Others : Anterior and posterior shield like cataracts are common Retinal detachment is common. Risk of endophthalmitis are common after cataract surgery.

26. Comparison of VKC and AKC VKC AKC Age Younger Older Sex Males> Females No predilection Duration of disease Limited,resolves at puberty Chronic Time of year Spring Perennial Conjunctival involvement Upper tarsus Lower tarsus Cornea Shield ulcer Persistent epithelial defect Conjunctival vascularisation Rare Common

27. Treatment of VKC and AKC General measures : Allergen avoidance Cold compression Lid hygiene maintain Bandage contact lens wear

28. Local treatment: Mast cell stabilizers -Sodium cromoglicate,Nedocromil sodium Topical antihistamine - Epinastine,Bepotastine Combined action of antihistamine and mast cell stabilzers : Olopatadine,Ketotifen Topical steroid Drops and Ointment - Flurometholone,Prednisolone,Loteprednol .

29. Immunomodulators - Ciclosporin,Calcineurin inhibitors Supra-tarsal steroid Injection Non steroidal anti-inflammatory preparation - Ketorolac,Diclofenac Combined antihistamine and vasoconstrictorts - Antazoline with xylometazoline

30. Systemic treatment: Oral antihistamine Antibiotics Immunosuppressive agents Surgery: Superficial keratectomy Surface restoration surgery

31. Giant Papillary Conjunctivitis It is the inflammation of conjunctiva with formation of very large size papillae. It is also known as mechanically induced papillary conjunctivitis because of localised allergic response to a physically rough or deposited surface.

32. Causes are: 1.Contact lens wear 2. Ocular prosthesis 3.Exposed suture 4. Scleral buckles 5. Corneal surface irregularity 6. Filtering blebs

33. Clinical features: Symptoms Foreign body sensation Redness Itching Increased mucus production Blurring of vision Loss of contact lens tolerance

34. Signs: Superior tarsal hyperaemia and papillae present. Variable mucous discharge Focal apical ulceration and whitish scarring may develop on large papillae

35. Treatment Removal of offending stimulus. Ensure effective cleaning of contact lens or prosthesis. Topical: Mast cell stabilizers Antihistamine Topical Steroid NSAID

36. Phlyctenular Keratocojunctivitis It is a characteristic nodular affection ( phlycten ) occuring as an allergic response of the conjunctival and corneal epithelium. Here delayed hypersensitivity(Type 1V cell mediated) response to endogenous microbial proteins occur.

37. Causative allergens : Tuberculus protein Staphylococcus protein Moraxella axenfeld bacillus protein

38. Predisposing factors: Age group is between 3-15 years Incidence is higher in girls than boys Disease is more common in undernourised children Overcrowded and unhygienic living condition plays an important role. Incidence is high in spring and summer season.

39. Clinical Features: Presence of a pinkish white nodule surrounded by hyperaemia on bulbar conjunctiva. Mild irritation and reflex watering present Mucopurulent discharge may be present due to secondary bacterial infection.

40. Differential diagnosis Phlyctenular conjunctivitis needs to be differentiated from the episcleritis , scleritis and conjunctival foreign body granuloma. Presence of one or more whitish raised nodules on the bulbar cionjunctiva near the limbus , with hyperaemia usually of the surrounding conjunctiva,in a child living in bad hygienic conditions are the diagnostic features.

41. Treatment: Local therapy: 1.Topical steroid drops. 2. Antibiotic drops and ointment Specific therapy: Tuberculous infection, septic focus in the form of tonsillitis,adenoiditis or caries of teeth should be ruled out and treat them accordingly. General measurement: Improve the health of the child is important.

42. Contact Allergen Blepharoconjunctivitis Analogous to contact dermatitis. Acute or subacute T-cell mediated delayed hypersensitivity. Causes: - Reaction to eye drop constituents - Reaction to contact lens solutions - Mascara

43. Clinical features : Erythema, thickening, induration and sometimes fissure occur in eyelids Sometimes conjunctivcal reaction occur Treatment: Discontinuation of precipitant. Topical steroids