Allergic conjunctivitis of eye

1. Allergic Conjuntivitis
Dr Kawshik Nag
Phase B Resident
Chittagong Medical College

2.  Allergic conjunctivitis is the inflammation
of conjunctiva due to hypersensitivity
reactions which may be
immediate(humoral) or delayed(cellular).
 The conjunctiva is ten times more
sensitive than skin to allergens.

3. Types
 Acute allergic conjunctivitis
 Seasonal and Perennial allergic conjunctivitis
 Vernal keratoconjunctivitis.(VKC)
 Atopic keratoconjunctivitis.(AKC)
 Giant papillary conjunctivitis.(GPC)
 Phlyctenular keratoconjunctivitis.(PKC)
 Contact allergen blepharoconjunctivitis

4. Acute allergic conjunctivitis
 It is a common condition caused by an
acute conjunctival reaction to an
environmental allergen usually pollen.
 It is typically seen in younger children
after playing outside in spring or
summer.

5.  Clinical features:
1. Chemosis
2. Acute itching
3.Watering
 Treatment:
-Usually not
required
-Cold compression
can be used.

6. Seasonal And Perennial Allergic
Conjunctivitis
 These are common subacute conditions
which are distinguished from each other
by the timming of exacerabations

7. Seasonal allergic conjunctivitis:
- It is more common
- Worse during the spring and summer
- Common allergens are grass and pollens
 Perenneal allergic conjunctivitis:
- Causes symptoms through out the year
- Generally worse in the autumm
- Allergens are dust mites, animal dander,
fungal allergen
- Less common and milder.

8.  Clinical features:
- Acute or subacute
attacks of redness
- Chemosis
- Itching and watering
-Sneezing and nasal
discharge

9.  Treatment:
- Artificial tear
- Mast cell stabilizer
- Antihistamines
- Dual action of antihistamine and mast
cell
stabilizer
- Topical steroid
- Oral antihistamine

10. Vernal Keratoconjunctivitis
 Pathogenesis:
 It is a recurrent bilateral disorder in which both IgE
and cell mediated immune mechanism play
important role.
 Atopic background play an important predisposing
factor.
 Boys are more affected than girls and the onset of
age is 5 years onwards.
 Peak incidence is over late spring and summer.

11. Classification
 3 Types
1. Palpebral VKC
- Involves upper tarsal conjunctiva and
may be associated with significant corneal
disese
2. Limbal VKC
3.Mixed VKC

12. Diagnosis: `
 Palpebral disease:
Upper tarsal conjunctiva
of both eye involved.
Macropapillae arranged
in a cobble-stone like
appearance.

13.  Macropapillae can progress
into giant papillae.
 Mucus deposition between
giant papillae.
 White ropy discharge may
be present.

14.  Limbal disease:
 Gelatinous limbal
conjunctival papillae
present.
 Horner-Trantas dots
present

15. Vernal keratopathy:
 Superior punctate
epithelial erosions with
layer of mucus.
 Epithelial
macroerosions caused
by a combination of
inflammatory mediators
and a direct
mechanical effect from
papillae.

16.  Vernal corneal plaques
result from coating of
macroerosion with a
layer of exudates.
 Shield ulcer presents
as a shallow transverse
ulcer in upper part of
cornea.

17.  Pseudogerontoxon
can develop in
recurrent limbal
disease.
 Subepithelial scars
may present.
 Keratoconus and
other ectasia disease
is more common.
 Herpes simplex
keratitis is more
common here.

18. Atopic Keratoconjunctivitis
 It is a rare bilateral disease
 Typically develops in adulthood
 History of atopic dermatitis and asthma are
common
 About 5% have suffered from childhood VKC.

19.  Both IgE and cell mediated immune response
play role.
 Associated with significant visual morbidity
because it tends to be perennial and a wide
range of airborne environmental allergen

20. Diagnosis
 Eyelids:
 Lid margins are
chronically inflamed
 Chronic blepharitis
and madarosis may
present
 Keratinization of lid
margin may be
present.

21.  Hertoghe sign:
Absence of the lateral
portion of the eyebrows.
 Dennie-Morgan folds:
Lid skin folds caused by
persistent rubbing

22.  Conjunctiva:
 Normally involves
inferior palpebral
conjunctiva.
 Hyperaemia,
chemosis and watery
discharge present.
 Papillae are usually
small.
 Diffuse conjunctival
infiltration and
scarring present

23.  Cicatricial changes
causes symblepharon
formation and
forniceal shortening.
 Keratinization of
caruncle.
 Horner-trantas dots
sometime present.

24.  Keratopathy:
 Punctate epithelial
erosions over inferior
third of the cornea.
 Peripheral
vascularization and
stromal scarring
present
 Persistant epithelial
defect may progress to
cornea perforation and
descemetocele
formation

25.  Others :
 Anterior and posterior
shield like cataracts
are common
 Retinal detachment is
common.
 Risk of
endophthalmitis are
common after cataract
surgery.

26. Comparison of VKC and AKC
VKC AKC
Age Younger Older
Sex Males> Females No predilection
Duration of
disease
Limited,resolves at puberty Chronic
Time of year Spring Perennial
Conjunctival
involvement
Upper tarsus Lower tarsus
Cornea Shield ulcer Persistent epithelial defect
Conjunctival
vascularisation
Rare Common

27. Treatment of VKC and AKC
 General measures:
 Allergen avoidance
 Cold compression
 Lid hygiene maintain
 Bandage contact lens wear

28.  Local treatment:
 Mast cell stabilizers
-Sodium cromoglicate,Nedocromil sodium
 Topical antihistamine
-Epinastine,Bepotastine
 Combined action of antihistamine and mast
cell stabilzers: Olopatadine,Ketotifen
 Topical steroid Drops and Ointment
-Flurometholone,Prednisolone,Loteprednol.

29.  Immunomodulators
-Ciclosporin,Calcineurin inhibitors
 Supra-tarsal steroid Injection
 Non steroidal anti-inflammatory preparation
-Ketorolac,Diclofenac
 Combined antihistamine and vasoconstrictorts
-Antazoline with xylometazoline

30.  Systemic treatment:
 Oral antihistamine
 Antibiotics
 Immunosuppressive agents
 Surgery:
 Superficial keratectomy
 Surface restoration surgery

31. Giant Papillary Conjunctivitis
 It is the inflammation of conjunctiva with
formation of very large size papillae.
 It is also known as mechanically induced
papillary conjunctivitis because of localised
allergic response to a physically rough or
deposited surface.

32.  Causes are:
1.Contact lens wear
2. Ocular prosthesis
3.Exposed suture
4. Scleral buckles
5. Corneal surface
irregularity
6. Filtering blebs

33. Clinical features:
Symptoms
 Foreign body sensation
 Redness
 Itching
 Increased mucus production
 Blurring of vision
 Loss of contact lens tolerance

34.  Signs:
Superior tarsal
hyperaemia and
papillae present.
Variable mucous
discharge
Focal apical
ulceration and
whitish scarring may
develop on large
papillae

35. Treatment
Removal of offending stimulus.
Ensure effective cleaning of contact lens
or prosthesis.
Topical:
Mast cell stabilizers
Antihistamine
Topical Steroid
NSAID

36. Phlyctenular Keratocojunctivitis
 It is a characteristic nodular affection
(phlycten) occuring as an allergic
response of the conjunctival and corneal
epithelium.
 Here delayed hypersensitivity(Type 1V
cell mediated) response to endogenous
microbial proteins occur.

37.  Causative allergens:
Tuberculus protein
Staphylococcus protein
Moraxella axenfeld bacillus protein

38.  Predisposing factors:
Age group is between 3-15 years
Incidence is higher in girls than boys
Disease is more common in
undernourised children
Overcrowded and unhygienic living
condition plays an important role.
Incidence is high in spring and summer
season.

39. Clinical Features:
 Presence of a pinkish
white nodule
surrounded by
hyperaemia on bulbar
conjunctiva.
 Mild irritation and
reflex watering present
 Mucopurulent
discharge may be
present due to
secondary bacterial
infection.

40. Differential diagnosis
 Phlyctenular conjunctivitis needs to be
differentiated from the episcleritis, scleritis
and conjunctival foreign body granuloma.
 Presence of one or more whitish raised
nodules on the bulbar cionjunctiva near the
limbus, with hyperaemia usually of the
surrounding conjunctiva,in a child living in
bad hygienic conditions are the diagnostic
features.

41.  Treatment:
 Local therapy:
1.Topical steroid drops.
2. Antibiotic drops and ointment
 Specific therapy:
Tuberculous infection, septic focus in
the form of tonsillitis,adenoiditis or caries of
teeth should be ruled out and treat them
accordingly.
 General measurement:
Improve the health of the child is
important.

42. Contact Allergen
Blepharoconjunctivitis
 Analogous to contact dermatitis.
 Acute or subacute T-cell mediated delayed
hypersensitivity.
 Causes:
- Reaction to eye drop constituents
- Reaction to contact lens solutions
- Mascara

43.  Clinical features:
 Erythema, thickening,
induration and
sometimes fissure occur
in eyelids
 Sometimes
conjunctivcal reaction
occur
Treatment:
 Discontinuation of
precipitant.
 Topical steroids