Allergic Eyes

Each spring we have many calls about eye symptoms. The frequency of this problem tends to be more in the month of April- perhaps the April showers and the significant winds stir up the pollen and the debris that has been frozen during those winter months.

I also suffer with eye allergy problems- allergic conjunctivitis. Grass pollen causes my eyes to itch, water, redden, and swell. My usual response is to rub the eyes and I know that rubbing just makes things worse. The oil, dirt, and grime from the hands will also cause the same symptoms as an allergen. The eye will respond with itch, tearing, redness, and swelling in response to an allergen, an infection, and an irritant.

At the most recent American Academy of Allergy, Asthma, and Immunology (AAAAI) meeting in March, I attended a session – The Diagnosis and Treatment of Ocular Allergy: A Practice Parameter Overview. This was an excellent session. There were three presentations;

  • Classification and Epidemiology by Sergio Bonini, MD
  • Pathogenesis and Diagnosis of Ocular Allergy by Andrea Leonardi, MD
  • Treatment of Ocular Allergy by Leonard Bielory, MD

Classification and Epidemiology

                There are a number of types of allergic conjunctivitis;

  • Intermittent or seasonal allergic conjunctivitis -usually seen with nasal symptoms
  • Persistent or perennial allergic conjunctivitis-also seen usually with nasal symptoms
  • Vernal keratoconjuncitivits-can occur alone or with asthma especially in young boys
  • Atopic keratoconjunctivitis-seen with atopic dermatitis
  • Contact lens conjunctivitis

Pathogenesis and Diagnosis of Ocular Allergy

                Seasonal allergic conjunctivitis is due to pollen. Trees tend to favor the spring. Grass pollen will begin towards late spring and early summer. Weed pollen would be in summer to late fall or until two killing frosts.

                Perennial allergic conjunctivitis would be due to house dust mites or to multiple allergens.

                The key symptom of the allergic eye is itch. If there is no itch, it is not due to allergy.

                Vernal keratoconjunctivitis is a more severe presentation and is seen mostly in children. In this variation of ocular allergy, there is intense itching, photophobia, a foreign body sensation in the eye, redness, and mucus secretion. The cornea can be involved. Interestingly, only 50% will show clear allergic sensitization with this condition.

 Making the diagnosis

                Get a good history

                No itch = no allergy

                The diagnosis of the seasonal form is clinical

                Vernal and atopic keratoconjunctivitis have unique features/signs

                If the skin of the eyelid is involved, consider a contact allergy

                Consider drug-induced conjunctivitis

                Air pollution may be a cause of eye allergy in those who live in the city

Treatment of Ocular Allergy

                The Allergic Conjunctivitis Practice Parameters (2010-under review) provide a stepwise approach.

                Acute Ocular Allergy

                Primary Treatment

  • Avoidance- >30% improvement in symptoms
  • Cold compresses- effective for mild to moderate symptoms
  • Preservative-free tears- soothing, try refrigeration to improve effect, cheap, comfortable, safe, use as needed
  • Contact lenses- act as a bandage/barrier, 67% improvement

 

                Secondary Treatment- Topicals

  • Antihistamines- help with itch
  • Antihistamines + Decongestants- help with itch and redness
  • Multiple Action Agents- perennial use
  • Mast Cell Stabilizing Agents- to prevent

               Tertiary Treatment

  • Oral antihistamines
  • Topical Steroids
  • Multiple Action Agents
  • Immunotherapy

Failure of conventional anti-allergy therapy treatment may require a consultation with an ophthalmologist

Pharmacologic Treatment (trade names appear in parentheses)

Topical agents

                Antihistamines

                                Levocabastine (Lecostin)

                                Azelastine (Optivar)

                                Pheniramine  (Opcon A, Naphcon A)

                Decongestants – These are available over-the-counter.

                                Naphazoline (Clear Eyes)

                                Oxymetazoline

                                Tetrahydrozoline (Visine)

                Multiple Action Antihistamines

                                Azelastine (Optivar)

                                Emedastine (Emadine)

                                Epinastine (Elestat)

                                Ketotifen (Acular or Zaditor-OTC)

                                Levocabastine (Levostin)

                                Olopatadine (Patanol)

                Mast Cell Stabilizers

                                Cromolyn (Crolom, Opticrom)

                                Lodoxamide (Alomide)

                                Nedocromil (Alocril)                    

                                Pemirolast (Alamast)

                Non-Steroidal Anti-Inflammatory Agents

                                Ketorolac (Acular)

                Corticosteroids

                                Loteprednol (Alrex)

                                Rimexolone (Vexol)

                                Fluorometholone (Allergan)

                                Prednisolone

                                Dexamethasone

Oral Agents

                Antihistamines

                                Ceterizine (Zyrtec)

                                Desloratidine (Clarinex)

                                Fexofenidine (Allegra)

                                Loratidine (Claritin)

                                Diphenydramine (Benadryl)

                                Chorpheniramine (Chlortrimeton)

                                Brompheniramine

                                Clemastine (Tavist)

                Decongestants

                                Pseudoephedrine (Sudafed) OTC

Nasal    

                Corticosteroid

                                Fluticasone (Flonase)

                                Mometasone (Nasonex)

                Antihistamine

                                Azelastine (Optivar)

This listing was taken from  Bielory et al, Treating the Ocular Component of Allergic Rhinoconjuncitivitis: Treatment Options for Ocular Allergy

 Other things to consider

  • Take a shower and wash the hair prior to going to bed to help get the pollen out of the hair and skin
  • Keep the windows closed at night
  • Do not dry laundry outside
  • Try not to use a fan that directly blows on the child, try to pull hot air out
  • Be very careful on those windy days

Summation

                Ocular allergy is a real problem with children. Of all the approaches to treatment I would advice first the practice of avoidance. If possible get away from the environment that brought on the symptoms. Next, keep the hands out of the eyes, this is the most common way a child deals with the problem of itchy eyes, but this only makes things worse. Third, an eye flush should be tried. Keep in mind some of the easy things you can do at home- chill the eye drops, cool compresses help too.

                There are a wide variety of medications for the eye and they offer different degrees of help. I am always hesitant about the ocular steroids and I try to get an ophthalmologist involved.

FEL

April 14, 2011 · fleickly · No Comments
Tags: , ,  · Posted in: Allergies, Conjunctivitis, Eye Allergy, Ocular Allergy