Dr Rachael Neiderer Ophthalmologist Auckland 8:35-8:50 Managing Allergic Conjunctivitis & Why Sodium Chromoglycate is Out
Allergic conjunctivitis Rachael 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 Onset Allergic conjunctivitis Viral conjunctivitis Blepharitis Bilateral, sudden or gradual Sudden, may occur in one eye first Itch +++ + Nil Gradual 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 Lids Allergic conjunctivitis Viral conjunctivitis Blepharitis Follicles Papillae Follicles Discharge Watery, mucoid Watery, mucoid Nil Crusting Blocked glands 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 Need to be prescribed by ophthalmologist 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
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