Ocular Allergy. Phil Lieberman, MD

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1 Ocular Allergy Phil Lieberman, MD

2 Disclosure Consultant/Advisory Board: Genentech, Meda, Mylan, Teva Speaker: Genentech, Meda, Merck, Mylan, Teva

3 Learning Objectives Upon completion of this session, participants should be able to : Distinguish ocular allergy from other eye disorders Correctly use pharmacotherapy to manage eye allergy

4 There Are Three Areas in Which You Are Likely to Be Tested How to distinguish allergic conjunctivitis from more threatening causes of the RED EYE Disease characteristics of the ALLERGIC EYE conditions Ocular drug pharmacology

5 How to Distinguish Allergic Conjunctivitis From More Threatening Causes of the RED EYE

6 Spectrum of Ocular Allergy Seasonal allergic conjunctivitis Perennial allergic conjunctivitis Vernal keratoconjunctivitis Atopic keratoconjunctivitis Giant papillary conjunctivitis

7 Threatening Eye Conditions Irtis Scleritis Episcleritis Acute glaucoma Herpes simplex and other forms of keratitis

8 Danger Sensitivity to light Pain exacerbated by light Different-sized, sluggish or fixed pupil Blurry vision Ciliary Flush

9 Ciliary Flush Injection of deep episcleral vessels around cornea Faint violet ring around cornea Causes Corneal inflammation Iridocyclitis Acute glaucoma Not seen in conjunctivitis

10 Ciliary Flush

11 Limbal Sparing

12 episclerits

13 scleritis

14 iritis

15 Acute angle closure glaucoma

16 Herpes Simplex

17 Disease Characteristics of the ALLERGIC EYE Conditions Vernal keratoconjunctivitis Atopic keratoconjunctivitis Giant papillary conjunctivitis

18 Vernal Conjunctivitis Age range: 5-20 Sex: Male > female Increased prevalence in dry climates Mediterranean basin Associated with atopic disorders (50% or more) Intense pruritus Photophobia Severe T-cell mediated disease involving the cornea: may be sight-threatening, shield ulcers

19 Vernal keratoconjunctivitis Ptosis of upper lid Stringy exudate Papillary hypertrophy cobblestoning Tranta s dots Horner s points Collection of epithelial and eosinophilic debris

20 Vernal Keratoconjunctivitis Typical giant papillae ( cobblestone ) May be associated with keratitis, shield ulcers (trauma, mediators, e.g., major basic protein) Trantas dots Limbal papillae with white apical gelatinous swellings (rich in eosinophils, fibroblasts, and necrotic epithelium)

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22 Vernal Shield Ulcers

23 Trantas Dots

24 Atopic Keratoconjunctivitis Perennial Affects those in teens, early 20 s Family or personal history of atopic dermatitis or adult eczema Burning is prominent symptom Corneal and/or lid involvement Superficial punctate keratitis, corneal infiltrates Papillae on lower tarsal conjunctiva

25 Atopic Keratoconjunctivitis Atopic cataracts anterior Tcell mediated Keratoconus Activity parallels activity of skin Conjunctivitis may be cicatrizing

26 Atopic Keratoconjunctivitis Palpebral eczema associated with dermatitis Corneal neovascularization with edema

27 Atopic Keratoconjunctivitis (AKC) Keratoconus Corneal ulcers Trantas dots (Horner s points)

28 Giant papillary conjunctivitis Trauma due to foreign body intolerance Contact lens, ocular prosthesis, sutures Extended wear SCL > hard CL > soft CL Aggravated by concomitant allergy Blurred vision, mucus production, Conjunctival injection Tarsal papillary reactions (>0.3 mm)

29 Giant Papillary Conjunctivitis Giant cobblestonelike papillae of the upper tarsal conjunctiva Associated with contact lens wear

30 Other conditions Vasomotor conjunctivitis Seborrhea Conjunctivitis Sicca Staphylococal blepharo-conjuncitvitis Meibomian gland dysfunction Rosacea

31 Seborrhea It is an excess production of oil or sebum by the skin's oil-producing sebaceous glands. Eyelid margin and conjunctival involvement producing oily and greasy lid crusting, follicular and papillary conjunctivitis, inferior punctate keratitis, and rarely loss of eye lashes. Lids, conjunctiva effected, blepharitis the most common manifestation

32 Ocular involvement in patients with seborrhea Blepharitis 54 Conjunctivitis 14 Dry eyes 7 Episcleritis 4 Superficial punctate staining JMJ 2005; Vol. 39 (1): 38-40

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34 Conjunctivitis Sicca Typical symptoms of keratoconjunctivitis sicca are dryness, burning and a sandygritty eye irritation that gets worse as the day goes on There may also be a stringy discharge Paradoxically there may be excessive tearing Dry eyes can usually be diagnosed by the symptoms alone

35 SICCA MILD

36 SICCA SEVERE

37 STAPHYLOCOCCAL LID INFECTIONS Staphylococcal blepharitis is not selflimited and is difficult to eradicate successfully It is a common cause of chronic conjunctivitis, recurrent epithelial keratitis, and recurrent morbidity.

38 STAPHYLOCOCCAL LID INFECTIONS Ulcerations at the base of the eyelashes Localized poliosis or canities (whitening) of individual eyelashes Short, misdirected, broken, sparse, or missing eyelashes Fine, epithelial keratitis

39 Staph STAPHYLOCOCCAL LID INFECTION

40 ACNE ROSACEA Lid and conjunctival involvement are common Hyperemia and dilation of the vessels and signs of staphylococcal infection of the lid margin

41 Rosacea

42 Rosacea

43 Approach to the Patient Does the eye itch Is the lid involved Nature of the discharge Is the patient atopic Are there any danger signals

44 Topical Therapies for Allergic Conjunctivitis Antihistamines Vasoconstrictors Antihistamine/vasoconstrictor combinations Mast cell stabilizers NSAIDs Corticosteroids Multiple mechanistic agents

45 Pharmacotherapy of Allergic Conjunctivitis: Multiple-action Antihistamine/Mast Cell Stabilizer Olopatadine Ketotifen Azelastine Bepotastine Epinastine Alcaftadine

46 Distribution of Mast Cell Phenotypes MCt MCtc Allergic Conjunctivitis VKC - Substantia Propria VKC - Epithelium GPC Small Intestine - Mucosa Skin Lung - Bronchial Epithelium Lung - Alveoli Nasal Mucosa - Epithelium Irani & Butrus 1990 Irani & Schwartz 1989

47 Thank You and A Good Luck Wink To All