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    Allergic Conjunctivitis (Allergic Conjunctivitides)

    Allergicconjunctivitis[1]

    Allergic conjunctivitis (AC) is the inflammation of the conjunctiva, the transparent, thin epidermal layer which covers the outer surface of the eye.

    The disease originates from this process: auto-immune.

    Presentation

    The classical symptoms of allergic conjunctivitis include itching, redness in the white of the eye, eyelid swelling, eye discharge, tearing, photophobia and foreign body sensation often associated with pain [4] [5], which usually concerns both eyes without compromising vision. Itching is undoubtedly the most typical of these symptoms, being reported by more than 75% of the people showing signs of AC [4]. Without itching the diagnosis of AC is suspect. Symptoms can sometime be seasonal and usually are marked in patients living in areas with warm and dry weather [5]. In certain situations the symptoms might affect patient’s life, limiting common activities like going outdoor, driving, or reading [4].

    According to the nature of allergen, there are 5 main types of AC:

    • Seasonal allergic conjunctivitis and perennial allergic conjunctivitis: Seasonal allergic conjunctivitis (SAC) is undoubtedly the most common form of ocular allergy [5] [6] and comes when the eye is exposed to allergens with seasonal occurrence like grass and weed pollens. The symptoms, conjunctival injection, chemosis and discharge, tend to last a few weeks and appear in different moments of the year [7]. The affected subjects tend to be symptom-free during winter months, when due to the meteorological conditions the airborne transmission of allergens decreases. Perennial allergic conjunctivitis (PAC) is a particular form of AC which presents itself when the symptoms become perennial. It is mainly due to house dust mite, mold or animal dander and is usually associated with perennial allergic rhinitis and symptoms like sneezing and runny nose. These signs tend to be worse each morning when the subject wakes up.
    • Vernal keratoconjunctivitis: Vernal keratoconjunctivitis (VKC) is characterized by the marked itching, burning and conjunctival injection, and sometime is associated with the involvement of the cornea. Other key symptoms include photophobia, intense lacrimation, watery discharge and eyelid heaviness. This type of conjunctivitis is bilateral, chronic and much less common in the general population, although particularly frequent in young boys. 
    • Atopic keratoconjunctivitis: The symptoms of atopic keratoconjunctivitis (AKC) are similar to those of VKC, even though they appear to be perennial. It is a manifestation of atopy, the predisposition to develop certain allergic hypersensitivity reactions and its symptoms might even appear after several years from the onset of the atopy itself. This inflammation involves the eyelids through a bilateral itching generally associated with the classical symptoms of watery discharge, redness, photophobia and pain. Loss of eyelashes and the appearance of papillary hypertrophy in the underside of the upper lid are also quite common. In severe cases, scarring of the conjunctiva, corneal neovascularization, ulcers an scars may occur.
    • Giant papillary conjunctivitis: Giant papillary conjunctivitis (GPC) is the inflammation of the conjunctiva [8] lining the upper eye generally associated with the use of contact lens. The exact cause of this condition is unclear, even though the possible reagent might be debris or dust caught behind the lens itself. The primary symptoms are itching, mucoid discharge and a persistent foreign body sensation when using contact lenses, which might result in a potential visual acuity reduction. Very common is also the emergence of small papillae that, when combined, can give the eye a cobblestone appearance. 

    AC can sometime be passed down from generation to generation in the same families, and might include reactions to some medicines such as eye drops or contact lens solutions.

    Skin
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  • Eyes
    Red Eye
    • eyes naphozoline pheniramine maleate (Visine-A): prescription, consult doctor if child is under 6 years; itchy, red eyes nedocromil sodium (Alocril): prescription, 3 years plus; itchy, tearing eyes lodoxamide (Alomide): OTC, 3 years plus; ocular inflammatory[sharecare.com]
    • If you have a red eye, you should see your eye doctor – don’t diagnose it yourself.[honolulueyeclinic.com]
    • All types of conjunctivitis cause a red eye, although not everyone with a red eye has conjunctivitis.[uptodate.com]
    • Signs are what the doctor can see (e.g. red eye), symptoms are what the patient describes to the doctor (e.g. pain).[medicalnewstoday.com]
    • It causes the blood vessels on the surface to dilate, and so it gives them a red eye and it causes a lot of itching, which is kind of far and away the most common symptom of true allergic conjunctivitis," said Dr.[kplctv.com]
    Chemosis
    • Chemosis (swelling of the conjunctiva) seen under the microscope … see my chemosis video 5.[rooteyedictionary.com]
    • The conjunctival injection and chemosis varies in severity.[reviewofoptometry.com]
    • […] thinning, infection, keratoconus, and vision loss Atopic keratoconjunctivitis: eyelid tightening, loss of eyelashes, cataracts Giant papillary conjunctivitis : eyelid inflammation and ptosis History of allergy, asthma, or eczema Itching (pruritus), chemosis[pathologyoutlines.com]
    • Chemosis and a characteristic boggy blepharedema of the lower eyelid are common.[merckmanuals.com]
    • Bilateral redness and watery discharge Itching (compared with the gritty, burning, irritation sensation of viral conjunctivitis) Assocation with hay fever, asthma and/or eczema Recent exposure to an allergen (not always identified) In some cases, marked chemosis[dermnetnz.org]
    Blepharitis
    • […] are characterised by: Redness and discharge in one or both eyes Diffuse redness around the globe including the underside of the upper and lower lids Adhesion of the upper and lower eyelids on waking Normal vision Absence of focal pathology (eg stye or blepharitis[dermnetnz.org]
    • The presence of the concurrent atopic dermatitis and blepharitis can aid in diagnosis of AKC.[reviewofoptometry.com]
    • Contact lenses and associated anterior segment disorders: dry eye, blepharitis and allergy.[contactlensupdate.com]
    • Differential diagnosis Infectious conjunctivitis Blepharitis Dry Eyes Syndrome Toxic conjunctivitis Ocular rosacea Keratitis Episcleritis/scleritis Angle Closure glaucoma Phlyctenular conjunctivitis Seasonal/Perennial Allergic Conjunctivitis Topical drops[eyewiki.aao.org]
    Excessive Tearing
    • See also conjunctivitis . observations Common signs include itching, burning, and swelling around the eyes and excessive tearing.[medical-dictionary.thefreedictionary.com]
    • Allergic conjunctivitis has been estimated to affect 20 to 40% of the population worldwide, and is characterized by itchiness, redness, and excessive tear production.[aldeyra.com]
    • tearing Sensitivity to bright light A doctor or eye care professional can diagnose conjunctivitis through an examination of your affected eye or eyes.[everydayhealth.com]
    • People with conjunctivitis may experience the following symptoms: A gritty feeling in one or both eyes Itching or burning sensation in one or both eyes Excessive tearing Discharge from one or both eyes Swollen eyelids Pink discoloration to the whites[aoa.org]
    Burning Eyes
    • Symptoms may be seasonal and can include: Intense itching or burning eyes Puffy eyelids, most often in the morning Red eyes Stringy eye discharge Tearing (watery eyes) Widened blood vessels in the clear tissue covering the white of the eye Your health[nlm.nih.gov]
    • Red, itchy, watery, and burning eyes are common symptoms of allergic conjunctivitis.[healthline.com]
    Ocular Pruritus
    • It typically presents as bilateral ocular pruritus, redness, and watery discharge.[uptodate.com]
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  • psychiatrical
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  • Entire body system
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  • Workup

    The clinical diagnosis is based on medical history, signs and symptoms, course of the disease, and physical exam findings. There are three main methodologies for diagnosing AC:

    • Revealing the presence of eosinophils
    • Revealing the presence of papillae in the everted upper lid with scraping
    • Revealing the presence of suspected allergens through positive skin tests

    In SAC and PAC, conjunctival scraping might not be sufficient to make the diagnosis of AC, because eosinophils are typically present in the deep layers of the substantia propria and therefore could go undetected with this superficial method. Measuring the levels of IgE in tears and allergen-skin prick testing may be used to test for the offending allergen. Other tear-specific markers such as EPC, IL-4 and IL-5 may also be useful for the diagnosis of AC. 

    In VKC conjunctival scraping is performed which shows an abundant presence of eosinophils. Through biopsy a marked quantity of mast cells within the substantia propria can also be detected. Eosinophils are numerous in AKC too, although no eosinophilic granule can be seen in this case, and mast cells and IgE can also be detected in greater quantities. Pronounced presence of inflammatory cells as well as elevated tear immunoglobulin levels characterize the diagnosis of GPC.

    Laboratory

    Serum
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  • Microbiology
    Staphylococcus Aureus
    • The most common types of bacteria that cause bacterial conjunctivitis include Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae and Pseudomonas aeruginosa.[allaboutvision.com]
    Candida
    • Common agents include Staph. aureus , Mycobacterium tuberculosis , Chlamydia and Candida . [4] Management [ edit ] A detailed history allows physicians to determine whether the presenting symptoms are due to an allergen or another source.[en.wikipedia.org]
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  • Treatment

    The treatment of allergic conjunctivitis involves a series of general measures, like avoiding the use of contact lenses until the symptoms have gone or trying not to rub the eyes. Home care can be added, which should be characterized by a combination of preventive strategies and activities to minimize allergen exposure, like closing the windows, keeping home dust-free, using an indoor air purifier or avoiding contact with harsh chemicals such as dyes and perfumes. In any case, it is important to detect the cause of the condition and try to avoid it. In this regard, it is useful to get a detailed history of the patient, which helps finding the cause of reaction or the offending allergen.

    In the more severe cases home care might not be enough, and more specialized measures might be needed. The inflammatory symptoms can be reduced by causing vasodilatation through the use of ocular decongestants and ocular steroids, or by blocking histamine action through the use of antihistamines or mast cell stabilizers. Immunotherapy is also gaining momentum as mainstay in ocular allergy management, especially with the sublingual immunotherapy SLIT [8] which appears to have a moderate effect on the signs and symptoms of this disorder [9].

    Treatment also varies based on the type of allergic conjunctivitis concerned. For example, the use of eye drops is particularly advised in seasonal and perennial conjunctivitis, since it allows to effectively reduce contact with the allergen and alleviate the ocular symptoms. Removal of the foreign body from the eye is the definitive treatment for giant papillary conjunctivitis, along with an improved contact lenses hygiene and a frequent contact lenses change. Permanent relocation to a cooler climate, with an easy management of the air-conditioned environment and dust particle control, is the most effective treatment for VKC and AKC, together with the use of mast cells stabilizers and corticosteroids. Some patients affected by AKC might even benefit from plasmapheresis [10].

    Prognosis

    Prognosis of AC is usually very favorable. Symptoms can be easily prevented or relieved with the appropriate medications and measures, and usually go away with treatment unless the subject continues to be exposed to the allergen. Complications are rare, but if left untreated they can cause major problems like keratitis (inflammation and ulceration of the cornea) or even permanent loss of vision which seriously affect the quality of life. 

    Complications

    Blepharitis
    • […] are characterised by: Redness and discharge in one or both eyes Diffuse redness around the globe including the underside of the upper and lower lids Adhesion of the upper and lower eyelids on waking Normal vision Absence of focal pathology (eg stye or blepharitis[dermnetnz.org]
    • The presence of the concurrent atopic dermatitis and blepharitis can aid in diagnosis of AKC.[reviewofoptometry.com]
    • Contact lenses and associated anterior segment disorders: dry eye, blepharitis and allergy.[contactlensupdate.com]
    • Differential diagnosis Infectious conjunctivitis Blepharitis Dry Eyes Syndrome Toxic conjunctivitis Ocular rosacea Keratitis Episcleritis/scleritis Angle Closure glaucoma Phlyctenular conjunctivitis Seasonal/Perennial Allergic Conjunctivitis Topical drops[eyewiki.aao.org]
    Allergic Rhinitis
    • Approximately, 1 in 3 people suffering from allergic rhinitis will develop asthma. 80 percent of asthmatic people suffer from allergic rhinitis.[health.ccm.net]
    • , it is estimated that 10% to 30% of adults and up to 40% of children are diagnosed with allergic rhinitis, making it the most chronic pediatric condition. 3 The prevalence of allergic rhinitis has increased substantially in recent decades in developed[clinicaladvisor.com]
    • The treatment of allergic conjunctivitis is similar to its counterpart, allergic rhinitis .[m.bkallergy.com]
    • Perennial allergic rhinitis typically occurs year-round, although many people notice some seasonal flares to their symptoms.[allergies.about.com]
    • .); and Xyzal (UCB SA.) are the newest in the class approved for allergic rhinitis.[eyetubeod.com]
    Tuberculosis
    • Common agents include Staph. aureus , Mycobacterium tuberculosis , Chlamydia and Candida . [4] Management [ edit ] A detailed history allows physicians to determine whether the presenting symptoms are due to an allergen or another source.[en.wikipedia.org]

    Etiology

    Conjunctivitis refers to any inflammation of the conjunctiva, which can be triggered by different agents. In the case of allergic conjunctivitis the agent concerned is an allergen, in other words any type of antigen which, although totally innocuous and harmless, is perceived by the body as a threat and fought off through an immune response. This type of conjunctivitis is common in people who already suffer for another allergic condition like hay fever or asthma [1].

    Causes

    Epidemiology

    Allergic conjunctivitis is very frequent and affects around 20% of the general population each year. About one-half of these people have a personal or a family history of atopy [2] which might have a hereditary nature. The occurrence of AC is very common, especially in the areas with high seasonal allergens and tropical and temperate climates, such as the Mediterranean, the Middle East or Africa. Many studies appear to underline the tendency of AC to become more and more frequent with the passing of time, perhaps due to the increased quantities in our environment of substances such as air pollution or cigarette smoke.

    Sex distribution
    Age distribution

    Pathophysiology

    Allergic conjunctivitis is usually a type I (immediate) hypersensitivity reaction coordinated by mast cells [3]. The allergen causes cross-linkage of IgE which triggers mast cell degranulation. The mast cells secrete histamine, tryptase, chymase, heparin, chondroitin sulfate, prostaglandins and other inflammatory mediators. Histamines in turn bind both to H1 receptors on the nerve endings, causing pruritus, and to H2 receptors on the blood vessel epithelial cells, causing the classical inflammatory symptoms of vasodilatation, migration of eosinophils and neutrophils and increased vascular permeability.

    Certain forms of AC may also be caused be mechanical irritation of the conjunctiva, often in due to contact lenses. The pathophysiological mechanism of vernal keratoconjunctivitis and atopic keratoconjunctivitis are not fully understood.

    The condition is frequently acute, but in the worst and most advanced cases it might turn into a chronic state, marked by remodeling of the ocular surface tissues [4]. Furthermore, as conjunctiva is very similar to the nasal mucosa from a molecular point of view, the allergens which trigger rhinitis usually provoke AC as well.

    Prevention

    The simplest and most effective measure to prevent allergic conjunctivitis is to limit the exposure to the environmental factors which trigger the inflammation. Identifying the allergens might be difficult, and collecting information about the personal and family history is highly recommended. This allows to pinpoint past allergic and inflammatory episodes which can help recognize the triggering factor. It might also be useful to follow general measures, such as frequently washing hands, not wearing contact lenses or not sharing personal items.

    Summary

    Allergic conjunctivitis (AC) occurs when the eye is exposed to allergens like pollen, mold, household dust and animal dander. The inflammatory reaction is characterized by the classical symptoms of redness, swelling and itching, which in this condition are combined with increased lacrimation. AC is very common among adults as well as children, and is popularly known as “pink eye”.

    Patient Information

    Allergic conjunctivitis (AC) is the inflammation of conjunctiva, the transparent thin epidermal layer which covers the white part of the eye. This inflammation occurs when the eye is exposed to allergens like pollen or mold, and is popularly known as “pink eye.” AC is very frequent and affects around 20% of the general population each year, especially those who already suffer for another allergic condition. The classical symptoms of AC include itching, redness in the white of the eye, eyelid swelling, eye discharge, tearing, photophobia and foreign body sensation, which usually interest both eyes.

    According to the triggering factor, AC can be categorized in the following 5 types:

    • Seasonal allergic conjunctivitis (SAC)
    • Perennial allergic conjunctivitis (PAC)
    • Vernal keratoconjunctivitis (VKC)
    • Atopic keratoconjunctivitis (AKC)
    • Giant papillary conjunctivitis (GPC)

    The diagnosis is usually made based on history, signs and symptoms, course of the disease and physical exam findings. Diagnostic tests such as conjunctival scraping, allergen-skin tests or biopsy may be needed to diagnose AC.

    The disorder can be treated by following a series of general measures, like closing the windows, or in the worst cases by using more specialized treatments such as using ocular decongestants or ocular steroids. The simplest and most effective AC prevention strategy is to limit the exposure to the environmental factors which trigger the inflammation itself, together with some commonsense measures like frequently washing hands or not sharing personal items.

    Other symptoms

    Stimulant
    • "That allergen will come in contact with the ocular surface and it will stimulate a release of histamine."[kplctv.com]
    • Vernal keratoconjunctivitis is a more serious form of allergic conjunctivitis in which the stimulant (allergen) is not known.[merckmanuals.com]
    • Immunomodulators, such as topical 0.05% cyclosporine and 0.03% tacrolimus, interact with the immune system either to stimulate or suppress.[reviewofoptometry.com]
    • The symptoms are due to release of histamine and other active substances by mast cells , which stimulate dilation of blood vessels, irritate nerve endings , and increase secretion of tears.[en.wikipedia.org]
    • It is believed that an antigen is present, in predisposed individuals, which stimulates the immunological reaction and the development of GPC.[emedicine.medscape.com]
    75%
    • It primarily occurs in boys and young men; about 75 percent of patients also have eczema or asthma.[acaai.org]
    • […] conjunctiva, common symptoms that occur in the eye include: ocular itching , eyelid swelling, tearing, photophobia , watery discharge, and foreign body sensation (with pain). [1] [3] Itching is the most typical symptom of ocular allergy, and more than 75%[en.wikipedia.org]
    • . • Itching—about 75% of individuals experience itching.[pharmacytimes.com]
    • Schweiz Med Wochescher. 1998, 75: 695-698.[waojournal.biomedcentral.com]
    Diphenhydramine
    • Diphenhydramine is dosed 3 or 4 times daily, every 4 to 6 hours.[pharmacytimes.com]
    • Diphenhydramine (Benadryl, also generic) is a short-acting, sedating antihistamine that can be taken at bedtime to reduce night-time itching.[uptodate.com]
    • Antihistamines [ edit ] Antihistamines such as diphenhydramine and chlorpheniramine are commonly used as treatment.[en.wikipedia.org]
    Phlyctenular Keratoconjunctivitis
    • Ocular examples of type IV hypersensitivity include phlyctenular keratoconjunctivitis, corneal allograft rejection, contact dermatitis, and drug allergies.[emedicine.medscape.com]
    Saccharomyces Cerevisiae
    • Most selectin blockers have failed phase II/III clinical trials, or the studies were ceased due to their unfavorable pharmacokinetics or prohibitive cost. [9] Sphingolipids, present in yeast like Saccharomyces cerevisiae and plants, have also shown mitigative[en.wikipedia.org]
    Ischemia
    • Selectin antagonists have been examined in preclinical studies, including cutaneous inflammation, allergy and ischemia-reperfusion injury.[en.wikipedia.org]
    Chlorpheniramine
    • Antihistamines [ edit ] Antihistamines such as diphenhydramine and chlorpheniramine are commonly used as treatment.[en.wikipedia.org]
    Alcohol Consumption
    • Eye redness can also be a result of minor irritations : blood vessels on the eye’s surface swell from the sun, wind, environmental dryness, chlorine, shampoo, dust, prolonged reading or computer use, or drug and alcohol consumption.[visioncarespecialists.com]

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    References

    1. Rosario N, Bielory L. Epidemiology of allergic conjunctivitis. Curr Opin Allergy Clin Immunol. 2011;11(5):471-476.
    2. O'Connell EJ. The burden of atopy and asthma in children. Allergy. 2004 Aug;59 Suppl 78:7-11.
    3. Liu G, Keane-Myers A, Miyazaki D, Tai A, Ono SJ. Molecular and cellular aspects of allergic conjunctivitis. Chem. Immunol. Chemical Immunology and Allergy 1999 73: 39–58.
    4. Whitcup SM. Recent advances in ocular therapeutics. Int Ophthalmol Clin 2006 46 (4): 1–6.
    5. Bielory L, Friedlaender MH. Allergic conjunctivitis. Immunol Allergy Clin North Am 2008 28 (1): 43–58, vi.
    6. Buckley RJ. Allergic eye disease—a clinical challenge. Clin. Exp. Allergy 1998 28 (Suppl 6): 39–43.
    7. Bielory L. Allergic conjunctivitis: the evolution of therapeutic options. Allergy Asthma Proc. 2012;33(2):129-139.
    8. Allansmith MR, Korb DR, Greiner JV, Henriquez AS, Simon MA, Finnemore VM. Giant papillary conjunctivitis in contact lens wearers. Am J Ophthalmol. May 1977;83(5):697-708.
    9. Calderon MA, Penagos M, Sheikh A, Canonica GW, Durham S. Sublingual immunotherapy for allergic conjunctivitis: Cochrane systematic review and meta-analysis. Clin Exp Allergy. 2011 Sep;41(9):1263-72.
    10. Aswad MI, Tauber J, Baum J. Plasmapheresis treatment in patients with severe atopic keratoconjunctivitis. Ophthalmology. Apr 1988;95(4):444-7.

    • Allergic conjunctivitis - L Bielory, MH Friedlaender - Immunology and allergy clinics of North , 2008 - Elsevier
    • Allergic conjunctivitis: update on pathophysiology and prospects for future treatment - SJ Ono, MB Abelson - Journal of allergy and clinical immunology, 2005 - Elsevier
    • A comparison of topical levocabastine and sodium cromoglycate in the treatment of pollen‐provoked allergic conjunctivitis - AB Frostad, AK Olsen - Clinical & Experimental Allergy, 2006 - Wiley Online Library
    • Allergic and immunologic disorders of the eye. Part II: ocular allergy - L Bielory - Journal of allergy and clinical immunology, 2000 - Elsevier
    • -comparison clinical study of ketorolac tromethamine 0.5% ophthalmic solution compared with placebo eyedrops in the treatment of seasonal allergic conjunctivitis - DG Tinkelman, G Rupp, H Kaufman, J Pugely - Survey of , 1993 - Elsevier
    • Comparison of the ocular efficacy and safety of diclofenac 0.1% solution with that of ketorolac 0.5% solution in patients with acute seasonal allergic conjunctivitis - J TAUBER, MB RAIZMAN - Journal of ocular , 1998 - online.liebertpub.com
    • Allergic Rhinitis - K Okubo, Y Kurono, S Fujieda, S Ogino, E Uchio - Allergology , 2011 - ai.jsaweb.jp
    • -comparison clinical study of ketorolac tromethamine 0.5% ophthalmic solution compared with placebo eyedrops in the treatment of seasonal allergic conjunctivitis - DG Tinkelman, G Rupp, H Kaufman, J Pugely - Survey of , 1993 - Elsevier
    • A randomized, double-masked trial of topical ketorolac versus artificial tears for treatment of viral conjunctivitis - Y Shiuey, BK Ambati, AP Adamis - Ophthalmology, 2000 - Elsevier
    • A novel murine model of allergic conjunctivitis - MT Magone, CC Chan, LV Rizzo, AT Kozhich - Clinical immunology and , 1998 - Elsevier
    • A randomized, placebo-controlled clinical trial of tacrolimus ophthalmic suspension 0.1% in severe allergic conjunctivitis - Y Ohashi, N Ebihara, H Fujishima - Journal of Ocular , 2010 - online.liebertpub.com

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