Dr Rachael NeidererOphthalmologist

Auckland

8:35 - 8:50 Managing Allergic Conjunctivitis & Why Sodium

Chromoglycate is Out

Allergic conjunctivitisRachael Niederer

Greenlane Clinical Centre, Auckland

Case

• 9 year old boy with red eye

• Itchy +++

• Watering ++

• Both eyes affected R > L

Is it allergic conjunctivitis

Differential diagnosis

• Allergic conjunctivitis

• Infectious conjunctivitis (esp viral)

• Blepharitis (usually older)

• Foreign body

• Scleritis

• Other: corneal ulcer, uveitis, angle closure

History

Allergic conjunctivitis Viral conjunctivitis Blepharitis

Onset Bilateral, sudden or gradual

Sudden, may occur in one eye first

Gradual

Itch +++ + Nil

Vision Normal Normal Normal

Photophobia Nil Nil Nil

POHx Prev allergic Sx Nil Hx gritty eyes

PMHx Atopy Recent URTI Rosacea

RED FLAGS• Blurred vision• Photophobia• Severe pain,

unable to sleep

Examination

Allergic conjunctivitis Viral conjunctivitis Blepharitis

Lids FolliclesPapillae

Follicles CrustingBlocked glands

Discharge Watery, mucoid Watery, mucoid Nil

Vision Normal Normal Normal

Cornea Normal Normal Normal

Pupil Normal Normal Normal

RED FLAGS• Blurred vision• Corneal lesion• Abnormal pupil

Blepharitis

HSV dendritic ulcer

Microbial keratitis (corneal ulcer)

Foreign body

Scleritis

Allergic conjunctivitis

• Acute hayfever conjunctivitis

• Seasonal allergic conjunctivitis

• Perennial allergic conjunctivitis

• Vernal keratoconjunctivitis

• Atopic keratoconjunctivitis

Vernal keratoconjunctivitis

• Age 9-19

• Boys > girls

• Warm climates

• Itching, redness, may have photophobia

• Signs: papillae, limbitis

• May develop shield ulcer

Shield ulcer

Atopic keratoconjunctivitis

• Adult onset

• Itch, photophobia, watering

• Signs: redness, fine papillary inflammation

• Periorbital atopic eczema

• Risk of secondary infection

• May develop corneal new vessels

Management

Simple things

• Stop rubbing!!

• Cold compresses

• Allergen avoidance

• Avoid non specific triggers: sun (sunglasses), wind, salt water (goggles)

• Topical lubricants (consider preservative free)

Topical treatment

• Topical antihistamine (e.g. livostin)

• Mast cell stabiliser• Sodium chromoglycate: need to use 6x daily, may

take 2 weeks to achieve therapeutic effect

• Lodaxamide (lomide): 2500x more potent inhibition of histamine release (animal models), more effective inhibition eosinophil activity, good for maintenance therapy but need very frequent dosing in acute exacerbation

Combined therapy

Dual action antihistamine and mast cell stabiliser

• Zaditor (ketotifen)

• Olopatadine (patanol)• Antihistamine, mast cell stabiliser and some cytokine inhibition

• Efficacy at least 12 hours

• Use twice daily

Steroids

• Great at relieving symptoms

• Short course can be very useful to get on top of symptoms

PROBLEMS:

• If diagnosis wrong, can make things worse

• Need to monitor intraocular pressure, can get quite marked pressure elevation, especially in children

• Long term risks: cataract, glaucoma

Need to be prescribed by ophthalmologist

Cyclosporine

• Immunosuppressant – initially used to treat transplant rejection

• Binds to cyclophilin in lymphocytes (especially T lymphocytes), preventing transcription and release of interleukin

• Directly inhibits eosinophil and mast cell activation

• Commonly used to treat dry eye and atopic disease in dogs

Cyclosporine

• 0.05% to 2.0% used for severe allergic eye disease (vernal, atopic)

• Steroid sparing agent

• Available as aqueous solution (Restasis 0.05%) or pharmacy compounded in oil

• Get reduced conjunctival fibroblast proliferation and increased tearing

Other options

Systemic immunosuppression

Surgery

• Debridement giant papillae

• Superficial keratectomy

Summary

• Large spectrum of disease

• Remember the simple treatments

• Stop rubbing!!

• Most common causes of visual loss are steroid complications and corneal scarring

Thank you Professor McGhee, Dr Trevor Gray, Dr Sue Ormonde and Dr David Pendergrast