Allergic Eye Disease - University of Cape Town · Allergic Eye Disease ... Vernal...
Transcript of Allergic Eye Disease - University of Cape Town · Allergic Eye Disease ... Vernal...
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Allergic Eye Disease
Rhian H. Grötte
Paediatric Ophthalmology
Red Cross Children’s Hospital and
UCT
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External eye infections are the commonest
reason for referral to primary eye
health clinics.
Allergic eye disease is the commonest reason
for chronic red eyes
not responsive to antibiotics.
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Simple Differential Diagnosis
If it itches it is allergy
If it burns it is dry eye
If the eyelids are stuck together in
the morning it is infection
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Ocular allergic diseases
• Ocular allergies affect approximately 15–
20%
of the population worldwide
• 90% of allergic disorders seen by an
allergist have an ocular component
• 93% of hay fever sufferers have
ocular symptoms
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The surface of the eye is the most obviously
exposed mucous membrane of the body
The conjunctival surface is accessible to allergens
and is the site of allergic reactions
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Stem Cell
Prelymphocyte
Lymphocyte
B lymphoctes
Plasmacell
IgG, IgA, IgM, IgD, IgE
antibodies
Thymus
T Lymphocytes
Helper T cells Th
Suppressor T cells Ts
Cytotoxic T cells Tc
Lymphokine producing
cells Tdh
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• Ocular urticaria / Acute allergic conjunctivitis (AAC)
• Allergic conjunctivitis seasonal (SAC ) and perennial (PAC)
• Vernal keratoconjunctivitis (VKC)
• Atopic keratoconjunctivitis (AKC)
• Giant papillary conjunctivitis ( GPC) (associated with contact lens wear)
Classification of ocular allergy
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Ocular Urticaria
Acute Allergic Conjunctivitis
Caused by a
sudden big
dose
of air borne
or hand borne
allergen
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Acute allergic conjunctivitis
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Hyperemia
Eyelid swelling
Chemosis
Papillary reaction
Seasonal/perennial
allergic conjunctivitis
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Allergic Rhinoconjunctivitis
Allergens react with IgE antibodies bound to conjunctival
mast cells
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Seasonal
Occurs in spring, autumn, or both
Grass, tree pollen, Early- and late-phase IgE
reactions
Perennial
Year round with more pronounced periods
Animal dander, dust mites, mould, spores
History of other atopic diseases
Early- and late-phase IgE reactions
Allergic rhinoconjunctivitis
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Seasonal
Itching (ocular and periocular)
Redness Burning
Excessive tearing
Stringy white mucus
Rhinitis
Perennial
Similar to seasonal allergic conjunctivitis
Milder than seasonal allergic conjunctivitis
More constant than seasonal allergic conjunctivitis
Seasonal exacerbations
Signs and symptoms of
allergic conjunctivitis
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Type I hypersensitivity reaction
• Acute or seasonal allergic conjunctivitis is
a type I hypersensitivity reaction
• The sequence of events involved in a type
I hypersensitivity reaction can be divided
into three phases
–Sensitization phase
–Activation phase (early allergic response)
–Late allergic response
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IgE
antibodies
Sensitized
mast cell
From Lichtenstein LM. Allergy and the immune system. Scientific Am. 1993; 269: 117-124
T lymphocyte
Antigen-presenting cell
Allergen in tears (1st exposure) Conjunctival epithelium
B lymphocyte
Plasma cell
Major
Histocompatibility
Complex
IL-4
IL-13
IL-5
IL-6
Allergic sensitization
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Allergen in tears (2nd exposure)
Basophil
Conjunctival epithelium
Activated mast cell
Eosinophil
Blood
vessel
Newly
synthesized Leukotrienes
Prostaglandins
Cytokines
PAF
Histamine Heparin
Chymase
Tryptase
ECF-A
Histamine releasing
factor
The early allergic response
From Lichtenstein LM. Allergy and the immune system. Scientific Am. 1993; 269: 117-124
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Activated
mast cell
Blood
vessel
Lipids
Cytokines
Chemokines
Histamine
Cytokines
Prostaglandins
Basophil
Eosinophil
Leukotrienes
The late allergic response
From Lichtenstein LM. Allergy and the immune system. Scientific Am. 1993; 269: 117-124
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Management options for
allergic conjunctivitis
• Simple non pharmacological remedies
• Oral Anthistamines
• Topical pharmacological treatment
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Simple Non-Pharmacological
Remedies
• Allergen avoidance
– Pet control
– Use air conditioning
– Avoid outdoor activities during high pollen
periods
• Cold compresses
• Lubricating eye drops
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Treatment Options for Allergic
Conjunctivitis
Oral Antihistamines
loratadine (Clarityne 10mg)
fexofenodine (Telfast 120mg)
cetirizine (Zyrtec 10mg)
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Topical Pharmacological Treatment
of Allergic Conjunctivitis
• Vasoconstrictors
• Antihistamines
• Mast cell stabilisers
• Non – steroidal anti-inflammatory drugs
• Corticosteroids
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Topical Antihistamines and
Vasoconstrictors
Antihistamines with Vasoconstrictors
Vasoconstrictors alone, phenylephrine, naphazoline oxymetazoline,
tetryzoline
(Oxylin , Prefrin ,Safyr Bleu )
Antazoline / naphazoline (Antistin-Privine)
Tetryzoline / Antazoline ( Spersallerg)
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Longer Acting Antihistamines
Emedastine (Emedine)
Levocabastine (Livostin ED)
Convenient twice a day dosage
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Mast Cell Stabilisers
Sodium Cromoglycate (Opticrom, Cromohexal,
Stop-Allerg, Vividrin)
4 times a day dosage
Long term benefit, not immediate relief
Stings
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Mast Cell Stabiliser with
Antihistamine Effect
Olopatadine ( Patanol)
Convenient 2x day dosage
Immediate relief of itch
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Mast cell Stabiliser with
Antihistamine and
Anti- eosinophil effects
Ketotifen (Zaditen)
Convenient 2x day dosage
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Non- steroidal Anti-inflammatory
Drugs
Diclofenac ( Voltaren)
Flurbiprofen (Ocufen)
Ketorolac ( Acular)
Anti-prostaglandin effect
3 or 4 x a day dosage
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• Ocular urticaria / Acute allergic conjunctivitis (AAC)
• Allergic conjunctivitis seasonal (SAC ) and perennial (PAC)
• Vernal keratoconjunctivitis (VKC)
• Atopic keratoconjunctivitis (AKC)
• Giant papillary conjunctivitis ( GPC) (associated with contact lens wear)
Classification of ocular allergy
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Vernal conjunctivitis and atopic conjunctivitis
differ from simple allergic conjunctivits
because they involve
• a cell mediated immune reaction
• much more severe signs
• have sight threatening complications.
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Epidemiology of Vernal Keratoconjunctivits
Pre-pubescent boys in warm dry climates 10% of all eye patients in East Jerusalem O’Shea 2000
0.5 – 1.0% of all patients in eye clinics worldwide Beigelmann 1950
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Vernal Keratoconjunctivitis
•Severe bilateral chronic recurrent ocular inflammation •Intense itch •Copious lardaceous stringy discharge •Starts pre-school •Burns out 10-14 years later •Usually lasts from September until Easter in Cape Town •Maybe the only allergic manifestation
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Vernal Keratoconjunctivitis
(Spring catarrh)
Limbal Type (black patients) Palpebral Type (white patients)
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Limbal Type Vernal Conjunctivitis
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Limbal Type Vernal Conjunctivitis
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Limbal Type Vernal
Conjunctivitis
Mucoid nodule Tranta's dots
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Resolved limbal infiltration
Inactive limbal
infiltration
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Tarsal papillae (cobblestones)
in white (palpebral) type vernal conjunctivitis
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Palpebral Type Vernal Conjunctivitis
Diffuse papillary hypertrophy on the upper tarsus
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Corneal Complications in Vernal Conjunctivitis
Punctate Keratitis
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Corneal Complications in Vernal Conjunctivitis
Epithelial macroerosion
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Corneal Complication in Vernal Conjunctivitis
Plaque formation ( Shield Ulcer)
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Corneal Complications in Vernal Conjunctivitis
Permanent subepithelial scarring
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The Aetiology of Vernal
Conjunctivitis
• Only 50% have +ve skin tests
• IgE raised in serum but not in tears
• A complex non IgE dependent
pathological mechanism involving Th2
immune lymphocytes
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The aetiology of Vernal Keratoconjunctivitis
Multitude of cells and mediators detected
eosinophilic mediators
Arachidonic acid derived mediators – prostaglandins,
leukotrienes
Substance P (a neuropeptide) raised
increased oestrogen and progesterone receptors
A Th2 driven mechanism
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Atopic keratoconjunctivitis
Affects young patients
with atopic dermatitis
Eyelids are red thickened
Macerated and fissured
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Palpebral eczema
associated with
dermatitis
Corneal neovascularization
with oedema
Atopic keratoconjunctivitis
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Atopic Conjunctivitis
Infiltration of tarsal conjunctiva
causing featureless appearance
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Atopic Conjunctivitis
Often progresses to tarsal papillae ( cobblestones)
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Punctate epithelialopathy Plaque formation
Corneal Scarring Corneal Vascularisation
Corneal complications in atopic conjunctivitis
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The upper tarsal conjunciva in giant papillary conjunctivitis
Giant papillary Conjunctivitis
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Different cell types infiltrate the
conjunctiva
AAC SAC PAC
Mast cells
Eosinophils
Neutrophils
VKC AKC GPC
T cells
Eosinophils
Mast cells
Neutrophils
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Treatment of Vernal Keratoconjunctivitis
Mast cell Stabilising Eye drops
+/-
Steroid Eyedrops
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The Old Gold Standard
G. Cromoglycate QID
+
G. Fluoromethalone QID
+/-
Oc. Dexamethazone nocte
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The New Approach
G. Ketotifen bd + G. Fluoromethalone bd
OR
G. Olopatidine + G. Fluoromethalone bd
+
Oc. Dexamethozone nocte
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Treatment of Vernal Keratoconjunctivitis
in the Future
Inhibition of the Th2 immune cell response
Tacrolimus more promising than cyclosporine